HOW NEW ARE “MODERN ANESTHESIA” TECHNIQUES?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

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Point/Counterpoint: Modern anesthesia techniques are radically different from the methods of twenty years ago. True or false?

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

Medication                        Year introduced

Propofol                              1989

Sevoflurane                        1995

Nitrous oxide                     1846

Fentanyl                               1959

Versed                                   1985

Rocuronium                        1994

Succinylcholine                  1952

Zofran                                  1991

Bupivicaine                          1957

 

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

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

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

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

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

 

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

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

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

 

In closing:

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

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

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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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

 

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For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: WHAT IS MALIGNANT HYPERTHERMIA?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

 

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Patients frequently have concerns and misunderstandings regarding Malignant Hyperthermia. Patients wonder what the disease is, if it could possibly strike them during anesthesia, and how the disease would be treated.

The word “malignant” in Malignant Hyperthermia has nothing to do with malignancy or cancer. Hyperthermia is the medical term for high temperature, and Malignant Hyperthermia, or MH, refers to an acute medical disorder associated with dangerously elevated body temperature. MH is rare, life threatening, and triggered by general anesthetic drugs. The disease runs in families. For this reason, if any of your ancestors or relatives died during anesthesia it’s important you reveal that fact to your anesthesiologist.

The inheritance is autosomal dominant, which means one of your parents must have had the disease for you to inherit it. To manifest MH, you must have both the gene for MH and also be exposed to one of the triggering anesthetic drugs. The triggering drugs are succinylcholine (a paralyzing drug/muscle relaxant) and the potent inhaled anesthetic gases sevoflurane, desflurane, isoflurane, or halothane.

The incidence of MH varies from 1:5000 to 1:100,000 anesthetics. Most MH cases appear during a patient’s first anesthetic, therefore most MH cases appear in children or young adults. I’ve performed 25,000 anesthetics over 30+ years, and none of my patients have developed MH. Nonetheless, every anesthesiologist must be knowledgeable and ready to diagnose and treat an MH crisis should one occur.

The clinical signs of MH are increased temperature, increased heart rate, increased breathing rate, and increased carbon dioxide production. These changes are caused by increased metabolism within muscle cells. The onset of MH causes individual muscle cells to become hypermetabolic, which leads to increased heat, increased carbon dioxide production, and acidosis in the bloodstream. As temperature increases, the heart beats faster and the lungs hyperventilate to blow off the excessive carbon dioxide and acid production from the muscle cells.

Early diagnosis can be difficult. There is no specific blood test to diagnose the disease. If a child receiving his first anesthetic develops a temperature of 104 degrees Fahrenheit, a heart rate of 180 beats per minute, and a respiratory rate of 60 breaths per minute, the diagnosis is apparent. As well, the patient’s jaw, trunk, or total body may become rigid. However, in some patients the initial presentation may only include increases in heart rate and respiratory rate, and high temperature may be a late sign.

A hallmark of diagnosis is evidence of increased carbon dioxide production. During surgery, anesthesiologists measure the carbon dioxide concentration of every breath you inhale and exhale. If the carbon dioxide concentration increases steadily in the context of increased heart rate and respiratory rate, with or without an increase in temperature, the anesthesiologist must suspect MH. Late clinical findings include hypertension, abnormal heart rhythms, poor blood supply to the extremities (skin turning bluish in color), and sudden unexpected cardiac arrest in children.

Blood tests drawn during MH show low pH (both metabolic and respiratory acidosis), elevated potassium, and elevated muscle enzymes (elevated CPK). The urine will become cola-colored (colored by myoglobin in the urine).

The emergency treatment for MH:

  1. Notify the surgeon. Stop the surgery as soon as possible.
  2. Call for help from all available MDs and RNs in the vicinity.
  3. Stop the triggering anesthetic drug(s).
  4. Administer dantrolene. Dantrolene is a specific inhibitor of the MH cascade within the muscle cells. All anesthetizing locations are required to have a supply of dantrolene on site. The drug is manufactured in a powdered form, and must be mixed with sterile water to form an injectable solution. Large doses of dantrolene (2.5 mg/kg, which is 8 vials of dantrolene powder for an average-sized man) must be given IV as soon as possible. Doses may be repeated as needed, for a total dose up to 30 mg/kg if necessary.
  5. Administer sodium bicarbonate IV to buffer acidosis.
  6. Cool the patient. This can be done by applying bags of cold fluid to the skin surface, administering cold IV fluids, or by immersion of the body into an ice bath if available.
  7. Treat abnormal heart rhythms with appropriate IV cardiac drugs.
  8. Treat elevated potassium levels with hyperventilation, and empiric administration of calcium chloride, insulin, and glucose IV.
  9. Draw blood tests for electrolyte levels/arterial blood gas determinations, insert a catheter into the bladder to monitor urine output, and insert a catheter into the radial artery at the wrist to monitor blood pressure and for intravascular access for rechecking the levels of acidosis and potassium in the blood.
  10. Prepare for transfer to an intensive care unit.

If a family member of yours died during anesthesia and you don’t know if they died because of MH, your doctor may advise you to have a muscle biopsy to determine if you are MH susceptible. This biopsy of the anterior thigh muscle (quadriceps) is done under local anesthesia. You are not at risk of developing MH during local anesthesia.

If a family member of yours died during anesthesia and you don’t know if they died because of MH, and you choose not to undergo a muscle biopsy, you should wear a MedicAlert bracelet that states that you are susceptible to Malignant Hyperthermia, and all your anesthetic care should be done with trigger-free anesthetics (as listed below).

If you have a positive muscle biopsy test for MH, or if a family member of yours had well-documented MH, you should wear a MedicAlert bracelet that states you are susceptible to Malignant Hyperthermia, and all your anesthetic care should be done with trigger-free anesthetics (as listed below).

A trigger-free anesthetic includes no succinylcholine, sevoflurane, isoflurane, desflurane, or halothane. A trigger-free anesthetic includes any of the following:

  1. Local anesthesia, with or without sedation with IV drugs such as Versed, fentanyl, or propofol.
  2. Regional anesthesia, such as spinal anesthesia, epidural anesthesia, or a regional nerve block, with or without sedation with IV drugs such as Versed, fentanyl, or propofol.
  3. A general anesthetic without succinylcholine, sevoflurane, isoflurane, or desflurane. A typical recipe would include all intravenous drugs, e.g. Versed as a premed, propofol for anesthetic induction, rocuronium for paralysis/muscle relaxation, fentanyl or remifentanil infusion for pain relief, and possibly ketamine. The gas nitrous oxide can also be used.

In the 1980’s, prior to the availability of dantrolene, the mortality from an MH episode was greater than 80%. In the 21st century, the mortality from an MH episode should be less than 5%.

For further information, I refer you to http://www.mhaus.org, the website of the Malignant Hyperthermia Association of the United States.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

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

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

HOW LONG WILL IT TAKE ME TO WAKE UP FROM GENERAL ANESTHESIA?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

One of the most frequent questions I hear from patients before surgery is, “How long will it take me to wake up from general anesthesia?”

 

The answer is, “It depends.”

Your wake up from general anesthesia depends on:

  1. What drugs the anesthesia provider uses
  2. How long your surgery lasts
  3. How healthy, how old, and how slender you are
  4. What type of surgery you are having
  5. The skill level of your anesthesia provider

In best circumstances you’ll be awake and talking within 5 to 10 minutes from the time your anesthesia provider turns off the anesthetic. Let’s look at each of the five factors above regarding your wake up from general anesthesia depends on:.

  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON WHAT DRUGS THE ANESTHETIST USES. The effects of modern anesthetic drugs wear off fast.
  • The most common intravenous anesthetic hypnotic drug is propofol. Propofol levels in your blood drop quickly after administration of the drug is terminated, resulting in rapid awakening.
  • The most common inhaled anesthetic drugs are sevoflurane, desflurane, and nitrous oxide. Each of these gases are exhaled from the body quickly after their administration is terminated, resulting in rapid awakening.
  • The most commonly used intravenous narcotic is fentanyl. Fentanyl levels in your blood drop quickly after administration of the drug is terminated, resulting in rapid awakening.
  • The most commonly used intravenous anti-anxiety drug is midazolam (Versed). Midazolam levels in your blood drop quickly after administration of the drug is terminated, resulting in rapid awakening.
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON HOW LONG YOUR SURGERY LASTS
  • The shorter your surgery lasts, the less injectable and inhaled drugs you will receive.
  • Lower doses and shorter exposure times to anesthetic drugs lead to a faster wake up time.
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON HOW HEALTHY, HOW OLD, AND HOW SLENDER YOU ARE
  • Healthy patients with fit hearts, lungs, and brains wake up sooner
  • Young patients wake up quicker than geriatric patients
  • Slender patients wake up quicker than very obese patients
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON WHAT TYPE OF SURGERY YOU ARE HAVING
  • A minor surgery with minimal post-operative pain, such a hammertoe repair or a tendon repair on your thumb, will lead to a faster wake up.
  • A complex surgery such as an open-heart procedure or a liver transplant will lead to a slower wake up.
  1. YOUR WAKE UP FROM ANESTHESIA DEPENDS ON THE SKILL LEVEL OF YOUR ANESTHETIST
  • Like any profession, the longer the duration of time a practitioner has rehearsed his or her art, the better they will perform. An experienced pilot is likely to perform smoother landings of his aircraft than a novice. An experienced anesthesiologist is likely to wake up his or her patients more quickly than a novice.
  • There are multiple possible recipes or techniques for an anesthetic plan for any given surgery. An advantageous recipe may include local anesthesia into the surgical site or a regional anesthetic block to minimize post-operative pain, rather than administering higher doses of intravenous narcotics or sedatives which can prolong wake up times. Experienced anesthesia providers develop reliable time-tested recipes for rapid wake ups.
  • Although I can’t site any data, I believe the additional training and experience of a board-certified anesthesiologist physician is an advantage over the training and experience of a certified nurse anesthetist.

YOUR WAKE UP FROM ANESTHESIA: EXAMPLE TIMELINE FOR A MORNING SURGERY

Let’s say you’re scheduled to have your gall bladder removed at 7:30 a.m. tomorrow morning. This would be a typical timeline for your day:

6:00            You arrive at the operating room suite. You check in with front desk and nursing staff.

7:00             You meet your anesthesiologist or nurse anesthetist. Your anesthesia provider reviews your chart, examines your airway, heart, and lungs, and explains the anesthetic plan and options to you. After you consent, he or she starts an intravenous line in your arm.

7:15             Your anesthesia provider administers intravenous midazolam (Versed) into your IV, and you become more relaxed and sedated within one minute. Your anesthesia provider wheels your gurney into the operating room, and you move yourself from the gurney to the operating room table. Because of the amnestic effect of the midazolam, you probably will not remember any of this.

7:30             Your anesthesia provider induces general anesthesia by injecting intravenous propofol and fentanyl, places a breathing tube into your windpipe, and administers inhaled sevoflurane and intravenous propofol to keep you asleep.

7:40            Your anesthesia provider, your surgeon, and the nurse move your body into optimal position on the operating room table. The nurse preps your skin with antiseptic, and the scrub tech frames your abdomen with sterile paper drapes. The surgeons wash their hands and don sterile gowns and gloves. The nurses prepare the video equipment so the surgeon can see inside your abdomen with a laparoscope during surgery.

8:00            The surgery begins.

8:45             The surgery ends. Your anesthesia provider turns off the anesthetics sevoflurane and propofol.

8:55             You open your eyes, and your anesthesia provider removes the breathing tube from your windpipe.

9:05             Your anesthesia provider transports you to the Post Anesthesia Care Unit (PACU) on the original gurney you started on.

9:10            Your anesthesia provider explains your history to the PACU nurse, who will care for you for the next hour or two. The anesthesia provider then returns to the pre-operative area to meet their next patient. Your anesthesia provider is still responsible for your orders and your medical care until you leave the PACU. He or she is available on cell phone or beeper at all times. No family members are allowed in the PACU.

10:40            You are discharged from the PACU to your inpatient room, or to home if you are fit enough to leave the hospital or surgery center.

YOUR WAKE UP FROM ANESTHESIA . . . TO REVIEW:

  1. Even though the surgery only lasted 45 minutes, you were in the operating room for one hour and 35 minutes.
  2. It took you 10 minutes to awaken, from 8:45 to 8:55.
  3. Even though you were awake and talking at 8:55, you were unlikely to remember anything from that time.
  4. You probably had no memory of the time from the midazolam administration at 7:15 until after you’d reached in the PACU, when your consciousness level returned toward normal.

I refer you to a related column AN ANESTHESIA PATIENT QUESTION: WHY DID IT TAKE ME SO LONG TO WAKE UP AFTER ANESTHESIA?”

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

DSC04882_edited

 

 

HOW TO WAKE UP PATIENTS PROMPTLY FOLLOWING GENERAL ANESTHETICS

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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.

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

 

 

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

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Clinical Case for Discussion: You’re anesthetizing a 60-year-old woman for a thyroidectomy. The surgeon tells you, “If this woman bucks on the endotracheal tube on awakening it could cause a neck hematoma and damage my surgical closure. Can you extubate her deep?”

Discussion: The patient has a normal airway, and she is healthy and slender. You decide to comply with the surgeon’s request and remove the endotracheal tube (ET tube) at the end of surgery while the patient is still fully anesthetized. You turn off the nitrous oxide, allow the patient to breath 100% oxygen and 3% sevoflurane, and suction the patient’s throat. You deflate the cuff on the ET tube and remove the tube. Once the tube is withdrawn, you turn off all anesthetics. At this point the patient coughs and her mouth fills with yellow gastric contents. You suction the mouth again, but the patient develops upper airway obstruction. The oxygen saturation drops to 80%. Your diagnosis is laryngospasm. You attempt to apply continuous positive airway pressure with an anesthesia mask, but her oxygen saturation falls to 70%. Panicked, you inject 100 mg of IV succinylcholine to re-paralyze the patient, and you perform laryngoscopy and reintubate her. After the ET tube is replaced, the oxygen saturation returns to 100%. You suction through the lumen of the ET tube, and you find yellow gastric material inside the lungs. You diagnose aspiration.

After a 10½ hour flight from Seoul, Korea, an Asiana airplane crashed on landing at San Francisco Airport on July 6, 2013. Aviation and anesthesia have similarities. The takeoff and landing of an airplane, just as induction and emergence from anesthesia, are more complex events than piloting the middle of a plane flight or managing the maintenance phase of a long anesthetic.

The timing of the removal of the endotracheal tube at the end of an anesthetic requires skill and judgment. Does deep extubation ever make sense? During my first year after residency training, a gray-haired anesthesia attending at my new medical center told me, “Richard, in private practice you never extubate anyone deep.” Twenty-seven years later, I’m writing to convince you he was right.

Let’s define “deep extubation.” Per Miller’s Anesthesia, 7th Edition, 2009, Chapter 50, “Extubation may be performed at different depths of anesthesia, with the terms ‘awake,’ ‘light,’ and ‘deep’ often being used. ‘Light’ implies recovery of protective respiratory reflexes and ‘deep’ implies their absence. ‘Awake’ implies appropriate response to verbal stimuli. ‘Deep’ extubation is performed to avoid adverse reflexes caused by the presence of the tracheal tube and its removal, at the price of a higher risk of hypoventilation and upper airway obstruction. Straining, which could disrupt the surgical repair, is less likely with ‘deep’ extubation. Upper airway obstruction and hypoventilation are less likely during ‘light’ extubation, at the price of adverse hemodynamic and respiratory reflexes.”

The medical literature describes deep extubation as extubating a patient who is still breathing 1.5 times the minimal alveolar concentration (MAC) of inhaled anesthetic. A 2004 study examined 48 children tracheally extubated while deeply anesthetized with 1.5 times the MAC of desflurane (Group D) or sevoflurane (Group S). No serious complications occurred in either group, and the time to discharge was not significantly different between groups. The study concluded that deep extubation of children can be performed safely with desflurane or sevoflurane. (Valley RD, Anesth Analg. 2003 May;96(5):1320-4, Tracheal extubation of deeply anesthetized pediatric patients: a comparison of desflurane and sevoflurane.)

In a prospective trial, 100 children age<16 years, each with at least one risk factor for perioperative respiratory adverse events (e.g. current or recent upper respiratory tract infection or asthma) were randomized to extubation under deep anesthesia or extubation when fully awake after tonsillectomy. There were no differences in respiratory adverse events (laryngospasm, bronchospasm, persistent coughing, airway obstruction, or desaturation <95%). Tracheal extubation in fully awake children was associated with a greater incidence of persistent coughing (60 vs. 35%, P = 0.028), however the incidence of airway obstruction relieved by simple airway maneuvers in children extubated while deeply anaesthetized was greater (26 vs. 8%, P = 0.03).

Seventy healthy patients between 2 and 8 yr of age who had elective strabismus surgery or tonsillectomy were randomly assigned to group 1 (awake extubation) or group 2 (anesthetized extubation). The incidence of airway-related complications such as laryngospasm, croup, sore throat, excessive coughing, and arrhythmias was not different between the two groups. The authors concluded that the anesthesiologist’s preference or surgical requirements may dictate the choice of extubation technique in otherwise healthy children undergoing elective surgery. (Patel RI, Anesth Analg. 1991 Sep;73(3):266-70. Emergence airway complications in children: a comparison of tracheal extubation in awake and deeply anesthetized patients).

In an informal poll of the private practice anesthesiologists at Stanford University, the incidence of deep extubation (i.e. patient extubated asleep while breathing >1.5 MAC of inhaled anesthetic) approached zero. Why do I and my colleagues avoid deep extubation? If you have a life-saving and life-preserving device such as an endotracheal tube safely in place in your patient, and your goal is to maintain the values of Airway, Breathing, and Circulation, why remove that life-preserving device prematurely without any evidence that such a removal is beneficial? Why leave your anesthetized patient with an unprotected airway?

I cannot cite you outcome data that shows awake extubation provides superior outcomes to deep extubation, but with modern short-acting anesthetics such as propofol, sevoflurane, and desflurane, a well-trained anesthesiologist can decrease anesthetic depth quickly and have their patient very awake within minutes after the conclusion of surgery. Per Miller’s Aesthesia, “Rapid recovery of consciousness shortens the at-risk time during extubation and may reduce morbidity, particularly in obese patients. … Nitrous oxide, sevoflurane, and desflurane all contribute to rapid recovery, particularly after prolonged procedures.”

If your patient vomits on emergence and the ET tube is still in situ, the cuff on the ET tube will protect their lower airway. And if you choose to extubate your patient awake, the occurrence of laryngospasm will be, in this author’s experience, rare.

It’s true that coughing on an ET tube can disrupt surgical repairs, increase intracranial pressure, increase intraocular pressure, or cause hypertension and tachycardia, but per Miller’s Anesthesia, “Marked increases in arterial blood pressure and heart rate occur frequently at the time of ‘light’ extubation. These effects are alarming but normally transient, and there is little evidence of adverse consequences.”

My advice: Use light levels of general anesthetics on your intubated patients, and learn how to wake your patients from general anesthesia quickly at the conclusion of surgery. Don’t suction the patient until you are ready to remove the ET tube, because the suction catheter stimulates early coughing.

The ET tube is your friend. I’d recommend you don’t pull it out until you’re certain you don’t need it any more.

The definitive reference from the medical literature on this topic is Popat M, Mitchell V, et al. Difficult Airway Society Guidelines for the management of tracheal extubation, Anaesthesia 2012, 67, 318-340.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

*
*
*
*

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

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

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Will you have an anesthesiologist for your wisdom teeth extraction surgery?

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.  Wisdom teeth can be extracted under local anesthesia alone, but most patients and oral surgeons do not prefer this option. 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.  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, but these are rarely used.

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 have no interest in publishing 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. (http://www.nbcbayarea.com/news/national-international/NATL—SD-24-Year-Old-Man-Dies-Following-Wisdom-Teeth-Removal-Surgery-201239551.html)

In 2011, a Baltimore-area teen died during wisdom teeth extraction. The family’s malpractice claim was settled out of court in 2013. (http://www.baltimoresun.com/news/maryland/howard/bs-md-ho-olenick-settlement-20130403,0,3496441.story).

Every general anesthetic carries a small risk, even when the patient is young and healthy, such as these two 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.  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?  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 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

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

Latest posts by the anesthesia consultant (see all)

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.

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. (Flick RP et al. Pediatrics 2011 Nov;128(5):e1053-61. Cognitive and behavioral outcomes after early exposure to anesthesia and surgery.)

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. (Sprung J, Flick RP et al, Mayo Clin Proc 2012 Feb;87(2):120-9. Attention-deficit/hyperactivity disorder after early exposure to procedures requiring general anesthesia.)

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. (Shen X, Dong Y,et al, Anesthesiology 2013 Mar;118(3):502-515.  Selective Anesthesia-induced Neuroinflammation in Developing Mouse Brain and Cognitive Impairment.)

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 (Eben Harrell, Anesthesia: Could Early Use Affect the Brain Later, Time, Nov 3, 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

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

Latest posts by the anesthesia consultant (see all)

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 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.

#4.  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 2003, 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.

#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

 

 

NEEDLE PHOBIA BEFORE GENERAL ANESTHESIA

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

Clinical Case for Discussion:  A needle-phobic 16-year-old male is scheduled for a shoulder arthroscopy at a freestanding surgery center.  He is tearful and refuses any needles while he is awake.  He is 5 feet 3 inches tall, weighs 220 pounds, and has a Body Mass Index of 39.

What would you do?

Discussion:  You bring the patient into the operating room and apply the standard monitors.  You begin an inhalation induction with 70% inspired nitrous oxide and sevoflurane.  You increase the concentration of sevoflurane gradually after each breath.  After 2 minutes, at 4% inspired sevoflurane, the patient begins to cough, buck, and have stridor, and the oxygen saturation plummets below 60%.  You see no site to place an I.V., and the nurse and surgeon are no help.  You are not able to improve the airway with jaw thrust, mask ventilation, continuous positive airway pressure, or an oral airway.  You place an laryngeal mask airway (LMA), but the patient continues to have stridor and a weak cough.  No ventilation is possible.  You give intramuscular succinylcholine at 4 mg/kg, but while you are waiting for the drug to take effect,  the patient’s ECG changes to ventricular fibrillation.  You scream for the defibrillator, and do direct laryngoscopy to attempt placement of an endotracheal tube in the now-flaccid patient.  Your heart rate is 180 beats–per-minute, and you are praying for the patient’s heartbeat to return.  You can’t believe that this boy walked into the surgery center as healthy as can be, and that within minutes you have brought on the circumstances of cardiac and respiratory arrest.

In a parallel universe, you anticipate all the above issues, and prepare yourself.  You are aware that his BMI = 39 places him at increased risk for an inhalational induction.  You explain to the patient and his parents that there are risks for an overweight patient being anesthetized without an I.V., and lobby hard for him to permit you to attempt an awake I.V. placement.  You offer him oral midazolam as an anti-anxiety premedication, and topical EMLA to numb the I.V. site.  Alas, he is crying and still refuses any needle. You place an automated blood pressure cuff on his upper arm, and note that veins are visible on his hand when you inflate the cuff in Stat mode on that extremity.  His airway appears normal.  You describe to the parents that there is a risk that their son might have dangerous low oxygen levels during the mask induction of anesthesia.  They agree to accept this risk, and you document the same in the medical records.  You make a plan to proceed with inhalation induction, using the automated cuff to maximize the size of the veins on his hand.

(Note:  If you do not have confidence in proceeding, you may delay the patient until another anesthesiologist is present to assist you, or cancel the case.  Also note that if the anesthetic is done in a hospital rather than a freestanding surgery center, the identical clinical issues will be present, and the anesthetic plan will be similar except for the presence of additional backup anesthesia personnel.)

You enter the operating room and apply the standard monitors.  You place a mask strap behind the patient’s head to help hold the anesthesia mask over his airway, and have him breathe 100% oxygen with high flows of 10 liters/minute for two full minutes prior to beginning induction.  Next you add 8% sevoflurane to the gas mixture, and ask the patient to take deep vital capacity breaths your anesthetic circle system.  This technique is known as Vital Capacity Rapid Inhalation Induction.  (Yurino M, A comparison of vital capacity breath and tidal breathing techniques for induction of anaesthesia with high sevoflurane concentrations in nitrous oxide and oxygen, Anaesthesia.1995 Apr;50(4):308-11).  For safety reasons, I prefer sevoflurane induction with 100% oxygen instead of using nitrous oxide, which limits the delivered oxygen concentration.

As soon as the patient is anesthetized deeply enough, (seeing the eyes conjugate in the midline is a useful monitoring sign), you activate the blood pressure cuff on his upper arm in the Stat mode, and you move to his lower arm to start the I.V.  You leave the patient breathing on his own with the straps holding the mask over his face, and use both of your hands to place a 20-gauge I.V. catheter.  Once the intravenous catheter is placed, you continue the anesthetic using intravenous and inhalation drugs, with either an LMA or endotracheal tube for airway management.

Ambulatory anesthesia in freestanding facilities is a gravy train of healthy patients and straightforward cases, right?  Not all the time.

In the hospital, when you anesthetize elderly, sick patients for complex surgeries, you have a multitude of advanced technologies at your disposal.  You have invasive monitoring, transesophageal echocardiogram machines, laboratories, blood banks, and intensive care unit backup, as well as dozens of other anesthesia providers available within seconds to assist you if you get into trouble.  In addition, it’s understood by the patient and family that there are significant risks if the patient is old, sick, or if the surgery is complex.

In anesthetics for healthy outpatient surgery, the patient and the family expect the rate of adverse outcomes to be … zero.  Despite your informed consent that rare problems could occur, there will be anguish and anger if problems indeed do occur.

Treat needle-phobia with respect.  It can be a life-threatening problem in the hands of an inexperienced anesthesia provider.

 

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

 

 

FACTS FOR LAYPEOPLE: DRUGS ANESTHESIOLOGISTS ADMINISTER

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

INTRAVENOUS MEDICATIONS:

1.  PROPOFOL.  Propofol is an intravenous sedative-hypnotic, and the most commonly used general anesthetic medication in the United States.  Because propofol can cause the patient to stop breathing, its use is restricted to physicians who are expert in the management of airway and breathing.  Propofol has ultra-fast onset and offset times, usually causing sleep within seconds of injection.  Because the drug is short-acting, it is often administered by a continuous intravenous drip or infusion When propofol is administered without other anesthetic drugs, the patient usually awakens within minutes of discontinuing the drug.  Propofol does not relieve pain, and most painful surgeries require additional medication(s).

2.  MIDAZOLAM (Brand name VERSED).  Midazolam is a short-acting anxiety-reducing drug of the Valium or benzodiazepine class.  Midazolam is commonly injected as the first drug to begin an anesthetic, because it gives patients a sense of calm, and often gives them amnesia for a period of minutes afterward.  Midazolam is a common drug given during sedation for colonoscopy procedures, because most patients have no awareness during the procedure, even though they are usually awake.

3.  NARCOTICS.  Most surgical procedures cause pain, and narcotic drugs are intravenous pain-relievers.  Commonly used narcotics are morphine, meperidine (brand name Demerol), fentanyl, and remifentanil.  Narcotics have the desired effect of dulling the brain’s perception of pain.  Narcotics cause sleepiness in higher doses, and have the common side-effect of nausea in some patients.  Morphine and Demerol are slower-onset, longer-lasting narcotics, while fentanyl and remifentanil are faster-onset, shorter-acting narcotics.

4.  PARALYZING DRUGS.  Some surgeries and anesthetics require the patient to be paralyzed, i.e. muscles must be rendered flaccid so that the patient can not move.  It is imperative that the patient be given adequate intravenous or inhaled anesthetic drugs first, so that the patient has no awareness that they can not move.  Commone paralyzing drugs are vecuronium, rocuronium, pancuronium, and succinylcholine.  Because paralyzing drugs cause the patient to stop breathing, their use is restricted to physicians who are expert in the management of airway and breathing.  Paralyzing drugs are used by anesthesia providers prior to the placement a breathing tube (endotracheal tube) into the patient’s windpipe (trachea).  Paralyzing drugs are used during certain surgical procedures in which the surgeon requires the patient’s muscles to be relaxed, for example, abdominal surgeries, some throat surgeries, and some surgeries inside the chest.

INHALED ANESTHETICS:

1.  POTENT INHALED ANESTHETICS.  Potent inhaled anesthetics include sevoflurane, isoflurane, and desflurane.  These drugs are liquids, administered via anesthesia vaporizers than turn them into inhaled gases.  They are usually administered in low concentrations (1% to 4% for sevoflurane, 1% to 2% for isoflurane, and 3% to 6% for desflurane), because sustained higher concentrations fo these drugs cause life-threatening depression of heart and breathing functions.  Because potent inhaled anesthetics can cause patients to stop breathing, their use is restricted to physicians who are expert in the management of airway and breathing.

2.  NITROUS OXIDE.  Nitrous oxide is a relatively weak inhaled anesthetic drug, usually administered in concentrations of 50% to 70%.  At these doses, nitrous oxide does cause significant sleepiness, but will not render the patient unconscious.  Nitrous oxide has the advantage of being a quick-onset, quick-offset drug, and it is non-expensive.  Because every patient must inhale a minimum of 21% oxygen, the maximum dose of nitrous oxide is 100 – 21, or 79%.  As a measure of safety, oxygen is usually administered at concentration of at least 30%, which is the reason why administered nitrous oxide concentrations rarely exceed 70%.

LOCAL ANESTHETICS:

1.  LIDOCAINE.  Lidocaine is injected into tissue to block pain at that site.  The onset of local anesthesia occurs within seconds, and the duration is short, usually less than one hour.  Lidocaine can be injected into the back during either a spinal anesthetic or an epidural anesthetic, to numb part of the patient’s body without causing unconsciousness.  Lidocaine can also be injected near major nerves, in what is called a nerve block.  Nerve blocks include injections to numb one arm, one leg, the hand, or the foot.

2. PROCAINE (Brand name Novocaine).  Although the term Novocaine is commonly heard, use of this drug has been largely abandoned, replaced by lidocaine instead.

3. BUPIVICAINE (Brand name Marcaine).  Bupivicaine is injected into tissue to block pain at that site.  The onset of local anesthesia occurs within minutes, and the duration is longer than lidocaine, usually from 2 – 6 hours, depending on the location of the injection.  Bupivicaine can be injected into the back during either a spinal anesthetic or an epidural anesthetic, to numb part of the patient’s body without causing unconsciousness.  Bupivicaine can also be injected near major nerves, in what is called a nerve block.  Nerve blocks include injections to numb one arm, one leg, the hand, or the foot.

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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

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

Latest posts by the anesthesia consultant (see all)

Clinical Case: 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:  

DSC04882_edited

 

 

CAN WE PREVENT AGITATION IN PEDIATRIC PATIENTS FOLLOWING ANESTHESIA?

the anesthesia consultant

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

Latest posts by the anesthesia consultant (see all)

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

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

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

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

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

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

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

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

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

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

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited