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

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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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

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

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

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

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

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

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

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

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

 

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

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

 

ANESTHESIA INDUCTION:

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

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

 

MONITORING THE PATIENT:

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

 

MAINTENANCE OF ANESTHESIA:

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

 

AWAKENING FROM ANESTHESIA:

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

 

THE ANESTHETIC FOR OUR CASE PRESENTATION ABOVE:

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

CHALLENGES OF DENTAL OFFICE ANESTHESIA:

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

 

BENEFITS OF DENTAL OFFICE SEDATION AND GENERAL ANESTHESIA:

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

 

HOW SAFE IS ANESTHESIA AND SEDATION IN A DENTAL OFFICE?

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

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

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

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

References:

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

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

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

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HOW TO WAKE UP PATIENTS PROMPTLY FOLLOWING GENERAL ANESTHETICS

THE ANESTHESIA CONSULTANT 14 Comments
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

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, (4th 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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:

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

 

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

DSC04882_edited

 

 

WILL YOU HAVE AN ANESTHESIOLOGIST FOR YOUR WISDOM TEETH EXTRACTION SURGERY?

THE ANESTHESIA CONSULTANT 20 Comments
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

In the United States, will you have an anesthesiologist for your wisdom teeth extraction surgery? If you are a healthy patient, the answer is: probably not.

In the United States, oral surgeons perform most wisdom teeth extraction surgeries.  This is a very common surgery, with the operation performed on up to five million times in the United States each year. Most patients are healthy teenagers.  Oral surgeons perform wisdom teeth surgeries in their office operating rooms, and most oral surgeons manage the intravenous sedation anesthesia themselves, without the aid of an anesthesiologist.

Oral surgeons are trained in the airway management and general anesthesia skills necessary to accomplish this safely, and a nurse assists the oral surgeon in delivering sedative medications.  Oral surgeons must earn a license to perform general anesthesia in their office. To administer general anesthesia in an office, most oral surgeons complete at least three months of hospital-based anesthesia training. In most states, oral surgeons then undergo an in-office evaluation by a state dental-board-appointed examiner, who observes an actual surgical procedure during which general anesthesia is administered to a patient. It’s the examiner’s job to inspect all monitoring devices and emergency equipment, and to test the doctor and the surgical staff on anesthesia-related emergencies. If the examinee successfully completes the evaluation process, the state dental board issues the doctor a license to perform general anesthesia.  Note that even though the oral surgeon has a license to direct anesthesia, the sedating drugs he or she orders are often administered by a nurse who has no license or training in anesthesia.

In an oral surgeon’s office, general anesthesia for wisdom teeth extraction typically includes intravenous sedation with several drugs:  a benzodiazepine such as midazolam, a narcotic such as fentanyl or Demerol, and a hypnotic drug such as propofol, ketamine, and/or methohexital.  Prior to administering these powerful drugs, the oral surgeon must be certain that he or she can manage the Airway and Breathing of the patient. After the patient is asleep, the oral surgeon injects a local anesthetic such as lidocaine to block the superior and inferior alveolar nerves.  These local anesthetic injections render the mouth numb, so the surgeon can operate without inflicting pain.  Typically, no breathing tube is used and no potent anesthetic vapor such as sevoflurane is used.  The oral surgeon may supplement intravenous sedation with inhaled nitrous oxide.

The oral surgeon has all emergency airway equipment, breathing tubes, and emergency drugs available. The safety record for oral surgeons using these methods seems excellent.  My review of the National Institutes of Health website PubMed reveals very few instances of death related to wisdom teeth extraction.  Recent reports include one patient who died in Germany due to a heart attack after his surgery (Kunkel M, J Oral Maxillofac Surg. 2007 Sep;65(9):1700-6.  Severe third molar complications including death-lessons from 100 cases requiring hospitalization).  A second patient died in Japan because of a major bleed in his throat occluding trachea, one day after his surgery (Kawashima W, Forensic Sci Int. 2013 May 10;228(1-3):e47-9. doi: 10.1016/j.forsciint.2013.02.019. Epub 2013 Mar 26. Asphyxial death related to postextraction hematoma in an elderly man).

Most oral surgeons do not publish their mishaps or complications, so the medical literature is not the place to search for data on oral surgery deaths. Deaths that occur during or after wisdom teeth extraction are sometimes reported in the lay press.  In April 2013, a 24-year-old healthy man began coughing during his wisdom teeth extraction in Southern California, and went into cardiac arrest.  He was transferred to a hospital, where he died several days later.

In 2011, a Baltimore-area teen died during wisdom teeth extraction. The family’s malpractice claim was settled out of court in 2013.

Every general anesthetic carries a small risk, such as these two reported cases of death following wisdom teeth extractions.  All acute medical care involves attending to the A – B – C ‘s of Airway, Breathing, and Circulation.  During surgery for wisdom teeth extraction, the oral surgeon is operating in the patient’s mouth. Surgery in the mouth increases the chances that the operation will interfere with the patient’s Airway or Breathing.  The surgeon’s fingers, surgical instruments, retractors, and gauze pads crowd into the airway, and may influence breathing.  If the patient’s breathing becomes obstructed, altering the position of the jaw, the tongue, or the neck is more challenging than when surgery does not involve the airway.

I’ve attended to hundreds of patients for dental surgeries.  For dental surgery in a hospital setting, anesthesiologists commonly insert a breathing tube into the trachea after the induction of general anesthesia.  A properly positioned tracheal tube can assure the Airway and Breathing for the duration of the surgery.  Because an anesthesiologist is not involved with performing the surgery, his or her attention can be 100% focused on the patient’s vital signs and medical condition.  When anesthesiologists are called on to perform general anesthesia for wisdom teeth extraction in a surgeon’s office, we typically use a different anesthetic technique.  Usually there is no anesthesia machine to deliver potent inhaled anesthetics, therefore intravenous sedation is the technique of choice.  Usually no airway tube is inserted.  When general anesthesia is induced in an office setting, the patient must have an adequate airway, i.e. and American Society of Anesthesiologists Class I or II airway. A typical technique is a combination of intravenous midazolam, fentanyl, propofol, and/or ketamine.  Oxygen is administered via the patient’s nostrils throughout the surgery. The adequacy of breathing is continuously monitored by both pulse oximetry and end-tidal carbon dioxide monitoring.  The current American Society of Anesthesiologist Standards for Basic Anesthetic Monitoring (July 1, 2011) state that “Every patient receiving general anesthesia shall have the adequacy of ventilation continually evaluated. … Continual monitoring for the presence of expired carbon dioxide shall be performed unless invalidated by the nature of the patient, procedure or equipment.”

The motto of the American Society of Anesthesiologists is “Vigilance.”  If the patient’s oxygen saturation and/or end-tidal carbon dioxide numbers begin to decline, an anesthesiologist will act immediately to improve the A – B – C ‘s of Airway, Breathing, and Circulation.

Let’s return to our opening question: Will you have an anesthesiologist for your wisdom teeth extraction surgery?  If you are a healthy patient, I cannot show you any data that an anesthesiologist provides safer care for wisdom teeth surgery than if an oral surgeon performs the anesthesia. The majority of wisdom teeth extractions in the United States are performed on healthy patients without an anesthesiologist, and reported complications are rare.  If you want an anesthesiologist, you need to make this clear to your oral surgeon, and ask him to make the necessary arrangements.  If you do choose to enlist a board-certified anesthesiologist for your wisdom teeth extractions, know that your anesthesia professional has completed a three or four year training program in his field, and is expert in all types of anesthesia emergencies.  As a downside, you will be responsible for an extra bill for the professional fee of this anesthesiologist.

Whether an anesthesiologist or an oral surgeon attends to your anesthesia, the objectives are the same:  Each will monitor the A – B – C ‘s of your Airway, Breathing, and Circulation to keep you oxygenated and ventilated, so you can wake up and leave that dental office an hour or so after your wisdom teeth extraction surgery has concluded.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

DOES REPEATED GENERAL ANESTHESIA HARM THE BRAINS OF INFANTS AND YOUNG CHILDREN?

THE ANESTHESIA CONSULTANT 3 Comments
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

Recent scholarly publications have raised the question whether repeated exposure to general anesthesia is harmful to the developing brain in infants and young children.  Millions of children have surgery under general anesthesia each year. Is repeated exposure to general anesthesia safe for the developing brain of your child? Let’s look at the evidence.

pediatric anesthesia

In 2011, a retrospective Mayo Clinic study looked at the incidence of learning disabilities (LDs) in a cohort of children born in Olmsted County, Minnesota, from 1976 to 1982.  Among the 8,548 children analyzed, 350 of the children received general anesthesia before the age of 2.  A single exposure to general anesthesia was not associated with an increase in LDs, but children who had two or more anesthetics were at increased risk for LDs.  The study concluded that repeated exposure to anesthesia and surgery before the age of 2 was a significant independent risk factor for the later development of LDs.  The authors could not exclude the possibility that multiple exposures to anesthesia and surgery at an early age adversely affected human neurodevelopment with lasting consequences.

The same group of Mayo Clinic researchers looked at the incidence of attention-deficit/hyperactivity disorder (ADHD) in children born from 1976 to 1982 in Rochester, Minnesota.  Among the 5,357 children analyzed, 341 ADHD cases were identified.  For children with no exposure anesthesia before the age of 2 years, the cumulative incidence of ADHD at age 19 years was 7.3%  Exposure to multiple procedures requiring general anesthesia was associated with an increased cumulative incidence of ADHD of 17.9%. The authors concluded that children repeatedly exposed to procedures requiring general anesthesia before age 2 years were at increased risk for the later development of ADHD.

Anesthesia scientists decided to study this problem in mice.  In March 2013, researchers at Harvard and other hospitals exposed 6- and 60-day-old mice to various anesthetic regimens. The authors then determined the effects of the anesthesia on learning and memory function, and on the levels of proinflammatory chemicals such as cytokine interleukin-6 in the animals’ brains. The authors showed that anesthesia with 3% sevoflurane for 2 hours daily for 3 days induced cognitive impairment (i.e., unusually poor mental function) and neuroinflammation (i.e., elevated levels of brain inflammatory chemicals such as interleukin-6) in young but not in adult mice. Anesthesia with 3% sevoflurane for 2 hours daily for 1 day or 9% desflurane for 2 hours daily for 3 days caused neither cognitive impairment nor neuroinflammation. Treatment with the non-steroidal anti-inflammatory (NSAID) drug ketorolac caused improvement in the sevoflurane-induced cognitive impairment. The authors concluded that anesthesia-induced cognitive impairment may depend on age, the specific anesthetic agent, and the number of exposures. The findings also suggested that cellular inflammation in the brain may be the basis for the problem of anesthesia-induced cognitive impairment, and that potential prevention and treatment strategies with NSAIDs may ultimately lead to safer anesthesia care and better postoperative outcomes for children.

The same Harvard research group assessed the effects of sevoflurane on brain function in pregnant mice, and on learning and memory in fetal and offspring mice. Pregnant mice were treated with 2.5% sevoflurane for 2 hours and 4.1% sevoflurane for 6 hours. Brain tissues of both fetal and offspring mice were harvested and immunohistochemistry tests were done to assess interleukin-6 and other brain inflammatory levels.  Learning and memory functions in the offspring mice was determined by using a water maze. The results showed that sevoflurane anesthesia in pregnant mice induced brain inflammation, evidenced by increased interleukin-6 levels in fetal and offspring mice.  Sevoflurane anesthesia also impaired learning and memory in offspring mice. The authors concluded that sevoflurane may induce detrimental effects in fetal and offspring mice, and that these findings should promote more studies to determine the neurotoxicity of anesthesia in the developing brain.

What does all this mean to you if your children need anesthesia and surgery?  Although further studies and further data will be forthcoming, the current information suggests that:  (1) if your child has one exposure to anesthesia, this may constitute no increased risk to their developing brain, and (2) repeated surgery and anesthetic exposure to sevoflurane may be harmful to the development of the brain of children under 2 years of age.  It would seem a wise choice to delay surgery until your child is older if at all possible.

What does all this mean to anesthesiologists?  We’ll be watching the literature for new publications on this topic, but in the meantime it seems prudent to avoid exposing newborns and young children to repeated anesthetics with sevoflurane.  Currently, sevoflurane is the anesthetic of choice when we put children to sleep with a mask induction, because sevoflurane smells pleasant and it works fast.  Children become unconscious within a minute or two.  After a child is asleep, it may be advisable to switch from sevoflurane to the alternative gas anesthetic desflurane, since the Harvard study on mice showed anesthesia with 9% desflurane for 2 hours daily for 3 days caused neither cognitive impairment nor neuroinflammation.  A second alternative is to switch from sevoflurane to intravenous anesthetics alone, e.g., to utilize propofol and remifentanil infusions instead of sevoflurane.

The concept of pediatric anesthesia harming the developing brain was reviewed in the lay press in Time magazine in 2009.  The four articles I summarized above represent the most recent and detailed advances on this topic.  Stay tuned.  The issue of anesthetic risk to the developing brain will be closely scrutinized for years to come.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

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

THE ANESTHESIA CONSULTANT 2 Comments
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

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:

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

STOLEN ANESTHETIC VAPORS

THE ANESTHESIA CONSULTANT Leave a comment
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.
emailrjnov@yahoo.com
Latest posts by THE ANESTHESIA CONSULTANT (see all)

Clinical Case: Your lead anesthesia technician reports that three full bottles of sevoflurane disappeared from three separate operating rooms, despite a light schedule in which all three rooms were finished by noon.  What do you do?

Vaporizer for liquid sevoflurane

 

Discussion:   What if someone stole the bottles of liquid anesthetic?  What if they kept them and used them to drug themselves?  Does this sound impossible?   Not so.  In her lecture Substance Abuse in Anesthesia Providers (2003 American Society of Anesthesiologists National Meeting, San Francisco), Roberta Hines, M.D., Professor and Chairperson at Yale, told the following story:  A talented, hard-working faculty member of her anesthesia department was found dead.  Numerous open bottles of sevoflurane were found in his locker at work.  The assessment was that he was abusing the sevoflurane by inhaling its fumes, and overdosed.   A similar case report was published (Burrows DL, Distribution of sevoflurane in a sevoflurane induced death, J Forensic Sci. 2004 Mar; 49(2):394-7), describing the following:  “The decedent was found lying in a bed with an oxygen mask containing a gauze pad secured to his face.  Three empty bottles and one partially full bottle of Ultane (sevoflurane) were found with the body.”

There have been published reports of propofol addiction by anesthesiologists, for example:   Iversen-Bermann S, Death after excessive propofol abuse, Int J Legal Med 2001; 114(4-5): 248-51.

The addiction risk with intravenous narcotics is well described and documented.  In Dr. Hines’ lecture, she cited the incidence of substance abuse in anesthesia residents as 0.4%, and the incidence in faculty as 0.1%.  In 76 – 90% of these cases, the primary abused drug was an opiate.  The government has strict rules regarding locking up controlled substances such as narcotics and benzodiazepines, and requiring documentation of all doses given to patients and all doses that are wasted.  The amounts of other drugs used, such as inhaled anesthetics or propofol used in infusions, are more difficult to quantitate.

Nobody talks much about addiction risks with non-narcotic anesthetics.  Substance abuse among anesthesiologists is something we do not celebrate.  People can be seriously harmed or killed by substance abuse of inhalational anesthetics or propofol.  Let’s be honest and admit that bottles of these drugs are sitting around operating rooms.  If vials of propofol or even half a bottle of sevoflurane were stolen, no one would miss them.  Is this a problem?  Sure it is.  What do we do?

The government makes us carefully document where every drop of narcotic or benzodiazepine goes.  If the government regulated the control of these other anesthetic drugs, we would have to come up with a system.  Perhaps all inhaled anesthetics bottles would be locked up, and a pharmacist would document the number of milliliters of each liquid at the end of every day.  Perhaps only one accountable person would be given the authority to handle the liquid and fill vaporizers.  For propofol, perhaps the number of cc’s signed out to each physician would be documented, all patient usage amount quantitated, and all waste returned as we do for narcotics now.

Outstanding training programs now educate their residents and staff on the risks of substance abuse, and offer Physician Well Being Programs for those who are at risk.  In addition, let me suggest that we should control the distribution of inhalational anesthetics and propofol.  Would this add extra hassles to our day?  With inhalational anesthetics, the changes would be a minor inconvenience.

Since Michael Jackson’s death, we are awaiting the American Society of Anesthesiologist’s recommendation on locking up or recording every milligram of propofol that is used or wasted by anesthesia professionals.  These changes will require extra paperwork or computer documentation for the pharmacy and for us, involving some elementary school mathematics.  I’m not looking to make the duties of an anesthesiologist more complex, but controlling where these life-threatening drugs go is crucial.

If you’re an anesthesia professional, it’s stupid to give yourself an anesthetic, no matter how depressed you get or how much difficulty you are having falling asleep on your own.

In addition to intravenous narcotic abuse and propofol abuse, the cases I’ve referenced above reveal the danger inherent in a stolen bottle of sevoflurane.

 

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

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CAN WE PREVENT AGITATION IN PEDIATRIC PATIENTS FOLLOWING ANESTHESIA?

THE ANESTHESIA CONSULTANT Leave a comment
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.
emailrjnov@yahoo.com
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Clinical Case of the Month:  A 5-year-old boy is scheduled for general anesthesia for a cochlear implant.  On your pre-operative phone call to the mother, she tells you that after the same surgery on the other ear, the child was severely agitated in the Recovery Room.  The last anesthesiologist told her that agitation was a common side effect for the sevoflurane anesthetic that was used.  What will you do?

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

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

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

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

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

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

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

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

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

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

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