HOW NEW IS “MODERN ANESTHESIA?”

the anesthesia consultant

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

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

1990s-moodboard

 

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

Medication                        Year introduced

Propofol                              1989

Sevoflurane                        1995

Nitrous oxide                     1846

Fentanyl                               1959

Versed                                   1985

Rocuronium                        1994

Succinylcholine                  1952

Zofran                                  1991

Bupivicaine                          1957

 

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

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

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

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

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

 

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

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

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

 

In closing:

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

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

 

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

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

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Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

 

 

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

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

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For questions, contact:  rjnov@yahoo.com

 

 

 

 

 

 

 

 

 

LESSONS LEARNED REGARDING SUGAMMADEX

the anesthesia consultant

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

8-2040-01

Regarding sugammadex and residual neuromuscular blockade: I’m aware of two cases of residual neuromuscular blockade which occurred during the past year. Both cases involved obese patients who required emergency reintubation. Both cases were near misses for brain death. Both of these near misses would never have occurred if sugammadex had been used.

The first case was a 50-year-old, 120 kilogram male for an endoscopic retrograde cholangiopancreatography (ERCP). The procedure was to be done in the prone position, and required endotracheal intubation. The intubation was easily performed, and was facilitated with 60 mg of rocuronium for paralysis. The patient was turned prone, and the procedure commenced. After only 15 minutes of operating time, the gastroenterologist announced that the procedure was over. Electrical nerve stimulation of the train of four (TOF) at the facial nerve with a Life Tech Mini Stim showed one twitch. The anesthesiologist injected 5 mg of neostigmine and 1 mg of glycopyrrolate IV, and the patient was turned supine. After ten minutes, the TOF nerve stimulation of the facial nerve showed four equal twitches, and the sevoflurane anesthesia was discontinued. The patient was allowed to return to spontaneous breathing, and he opened his eyes. The trachea was extubated. Within the first two minutes, the patient had inadequate strength for spontaneous respiration. On 100% oxygen via mask, his oxygen saturation dropped from 100% to 80%. 120 mg of succinylcholine was injected IV, and an emergency reintubation was performed. The repeat intubation was more difficult than the original intubation, and required two looks before the trachea was visualized. The nadir oxygen saturation was 60%. The patient was kept asleep for thirty additional minutes, until nerve stimulation at the ulnar nerve showed both TOF and sustained tetany without fade. At that point the trachea was extubated. The patient had no brain damage, and he was discharged home ninety minutes later.

The second case was a 45-year-old, 120 kilogram male with obstructive sleep apnea for a uvulopalatopharyngoplasty (UPPP) and tonsillectomy. The endotracheal intubation was easily done, and was facilitated with 70 mg of rocuronium for paralysis. The surgery lasted 60 minutes. The anesthesiologist injected 5 mg of neostigmine and 1 mg of glycopyrrolate IV fifteen minutes prior to the end of surgery. At the conclusion of surgery, electrical nerve stimulation of the facial nerve with a Life Tech Mini Stim showed four equal twitches in the TOF, and the sevoflurane anesthesia was discontinued. The patient was allowed to return to spontaneous breathing, and opened his eyes. The trachea was extubated. Within the first minute, the patient was awake and breathing, but had jerky breathing pattern and was unable to ventilate himself effectively. On 100% oxygen via mask, his oxygen saturation dropped from 100% to 70%. 200 mg of propofol and 120 mg of succinylcholine were injected IV, and an emergency reintubation was performed. The repeat intubation was more difficult than the original intubation because of blood in the mouth and the oral surgery, and required two looks before the trachea was visualized. The nadir oxygen saturation was 49%. The patient was kept asleep for thirty additional minutes until nerve stimulation at the ulnar nerve showed both TOF and sustained tetany without fade. At that point the trachea was extubated. The patient had no brain damage. He was a planned admission to the hospital, and the remainder of his hospital course was uncomplicated.

Several teaching points are warranted:

  1. If succinylcholine been used for the intubations, the large intubating doses of rocuronium would have been avoided, and the inadequate reversal of the rocuronium intubating doses would likely not have occurred.
  2. If smaller doses of rocuronium been used for intubation, the inadequate reversal of the rocuronium intubating doses would likely not have occurred.
  3. These two cases were done prior to sugammadex availability. In the era of sugammadex, beginning now in 2016, these two near misses should never occur. Sugammadex is a modified γ-cyclodextrin which shows a high affinity for rocuronium and vecuronium. Sugammadex forms a tight inclusion complex with either rocuronium or vecuronium, resulting in rapid reversal of neuromuscular blockade. Sugammadex is able to reverse a moderate profound neuromuscular blockade with a dose of 2.0 mg/kg, and a profound neuromuscular blockade with a dose of 4.0 mg/kg.(1) In my experience, these doses of sugammadex completely reverse rocuronium paralysis within 30-40 seconds. Inadequate neuromuscular blockade reversal should never occur in the era of sugammadex. The past practice of administering neostigmine plus glycopyrrolate to reverse neuromuscular blockade, and then waiting up to ten minutes, is an inferior pharmacologic measure when compared to sugammadex. Reversal with neostigmine plus glycopyrrolate is slow, unreliable, and at times incomplete. While it’s true that a 200 mg ampoule of sugammadex costs approximately $100, that sum of money is trivial when compared to the cost of the lawsuit that would have occurred if either of the two case studies above had resulted in brain death due to delayed or unsuccessful reintubation. In my medical-legal consulting practice I see multiple cases of failed or delayed endotracheal intubations that result in brain death and multimillion-dollar closed malpractice claims.
  4. Residual neuromuscular blockade cannot always be reliably excluded by using qualitative monitoring such as a Life Tech MiniStim device to monitor TOF. The TOF is monitored by comparing the amplitude of the fourth (T4) to the first (T1) evoked mechanical response at the facial nerve or the ulnar nerve. The T4/T1 ratio, or the TOF ratio, coincides with symptoms of peripheral muscle weakness.At a TOF ratio less than 0.60, signs of muscle weakness and ptosis are easily observed. When TOF ratios recover to 0.70, the majority of patients are able to sustain head lift and eye opening. A very low TOF ratio between 0.1 and 0.5 is easily detected by a qualitative nerve stimulator. However, TOF ratios between 0.5 and 1.0 can be difficult to discern visually. Many clinicians are unable to detect fade when TOF ratios exceed 0.30 to 0.4.(1) Qualitative neuromuscular monitoring of the facial nerve twitch can be deceiving. Applying the peripheral nerve stimulator to the ulnar nerve at the adductor pollicis is the gold standard, and this site must be used for the pre-reversal assessment even when the ulnar nerve and thumb are not accessible intraoperatively. Recovery from neuromuscular paralysis should be present when a TOF count without fade has been confirmed at the adductor pollicis.(2) In a partially paralyzed patient, a visually undetectable fade of the TOF at the facial nerve may coincide with a visually detectable fade in TOF when the ulnar nerve is tested. When a patient’s arms are tucked during surgery, or when the ulnar nerve area is distant from the anesthesiologist’s location, it may be impossible to test ulnar nerve stimulation intraoperatively. Prior to extubation, when the ulnar nerve is accessible, ulnar nerve stimulation will convey a more accurate assay of the level of neuromuscular reversal.
  5. Immediate reversal of neuromuscular blockade induced by rocuronium is possible with a larger dose of sugammadex of 16 mg/kg. To facilitate intubation, a dose of succinylcholine (1 mg/kg) will cause a neuromuscular blockade of 4 – 5 minutes in duration. If an airway is found to be difficult or if the intubation is found to be impossible, the anesthesiologist has no way to return the patient to spontaneous breathing until these 4 – 5 minutes elapse. To facilitate intubation, a dose of rocuronium (0.5 – 1 mg/kg), if immediately reversed by sugammadex 16 mg/kg, will cause a shorter duration of paralysis than if succinylcholine were used. It remains to be seen whether this fact will lead to increased use of rocuronium rather than succinylcholine in difficult endotracheal intubations in which a potential early return to spontaneous ventilation is deemed prudent.

 

Healthcare systems are likely to promote selective or infrequent utilization of the new neuromuscular paralysis antidote sugammadex because of its cost. For your practice, and for mine, use the drug when you need it. You’re not personally paying the $100 price for the dose of sugammadex. If you have a serious patient complication because of inadequate neuromuscular reversal by the old drug neostigmine, the adverse patient outcome and the resulting lawsuit may cost you a whole lot more than that $100.

For the record, I have no financial interest or investment in sugammadex. I just know a good product when I see one.

References:

  1. Murphy GS et al, Reversal (Antagonism) of Neuromuscular Blockade, Chapter 35, Miller’s Anesthesia, 8th Edition, 2015.
  2. Thilen SR, Qualitative Neuromuscular Monitoring: How to Optimize the Use of a Peripheral Nerve Stimulator to Reduce the Risk of Residual Neuromuscular Blockade, Curr Anesthesiol Rep. 2016;6:164-169.

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

41wlRoWITkL

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

DSC04882_edited

 

 

13 MAJOR CHANGES IN ANESTHESIOLOGY IN THE LAST TEN 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

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

final_ten_year_graphic_gif

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

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

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

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

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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

KIRKUS REVIEW

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

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

Nuanced characterization and crafty details help this debut soar.

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

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

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TRENDS FOR THE FUTURE OF ANESTHESIOLOGY

the anesthesia consultant

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

What can we expect in the next 10 years of anesthesiology? What will be the trends for the future of anesthesiology? I’m writing this in January 2016. God willing, we’ll all be alive and well to reread this in 2026, and find out how many of these predictions about the future of anesthesiology came true.

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I’m writing this from the perspective of a busy clinician who has worked as an anesthesiologist in California in both private practice and at a major university hospital for over 30 years. I see 10 trends for the future of anesthesiology as:

  1. Lower income (as adjusted for inflation). There will be multiple causes for this: a) An aging population, with the significantly lower pay for attending to Medicare patients, b) Obamacare and other governmental payment cuts, c) Bundled insurance payments to hospitals, requiring anesthesiologists to negotiate for every nickel of that payment due to them, and d) Corporate anesthesia (see #9 below).
  2. More care team anesthesia and more Certified Nurse Anesthetists (CRNAs). Hospital systems will have increased incentives to perform anesthetics with cheaper labor. Rather than physician anesthesiologists personally performing anesthesia, expect to see CRNAs supervised by physician anesthesiologists in an anesthesia care team, or in some states, CRNAs working alone.
  3. There will be a paucity of new drugs to change the practice of operating room anesthesia. A few years ago I had a conversation with Don Stanski, MD, PhD, former Chairman of Anesthesiology at Stanford and now a leading pharmaceutical company executive, regarding new anesthetic drugs in the pipeline. Dr. Stanski’s reply was something along the line of, “There are almost no new anesthetic drugs in development. The ones we currently have work very well, and the research and development cost in bring an additional idea to market is high. Don’t expect much change in the coming years.” Consider sugammadex, a new drug for the reversal of neuromuscular blockade, recently approved by the Food and Drug Administration. The drug is more effective in reversing a rocuronium or vecuronium block than is neostigmine, but the cost is high. The acquisition cost of the smallest available vial of sugammadex is over $90, far exceeding the cost of neostigmine. In certain instances, faster reversal by sugammadex will be critically important, but for routine cases the cost is prohibitive. This trend of fewer new anesthesia drugs isn’t only a futuristic phenomenon. In my current private practice, I see my colleagues using the same medications that they used 25 years ago: propofol, sevoflurane, rocuronium, fentanyl, and ondansetron.
  4. An aging population, an increased volume of surgery, and an increased demand for anesthesia personnel. As the baby boomers age, there will be an increased number of surgeries on older, sicker patients. Anesthesia personnel will be in great demand.
  5. Anesthesiology will become more and more a shift-work job. A generation ago an anesthesiologist started a case and finished that case. An on-call anesthesiologist came to work at 7 a.m., took 24-hour call, and finished their last case as the sun came up the next morning. Certain instances of this model may persist, but as more anesthesiologist become corporate employees, expect more anesthesia practitioners working 8-hour or 12-hour shifts, just like employees in other jobs.
  6. Increased interest in the specialty of anesthesiology amongst medical students. Although several items on my list may seem discouraging, take heart, because the career of anesthesiology will remain extremely popular. Why? Because the other fields of medicine have problems, too. Bigger problems. Many future doctors will shun the primary care fields of family practice, internal medicine, and pediatrics. The primary care fields offer long days in clinics, dealing with a new patient every 10 – 15 minutes, and they suffer from low pay. Because of the higher reimbursement in procedural specialties, careers in surgery, anesthesia, cardiology, and invasive radiology will always be popular.
  7. Expect improved safety statistics regarding anesthesia mortality and morbidity. Anesthesia has never been safer. See “How Safe is Anesthesia in the 21st Century?” Expect further improvements in monitors, protocols, education, and the analysis of Big Data that will make anesthesia safer than ever.
  8. There will still be a non-zero incidence of anesthesia-related fatalities. There will still be disasters, particularly airway disasters. Some anesthesia clinical situations will always remain extremely difficult and challenging, and human error will not be eradicated.
  9. Large national corporations will continue buying up private anesthesia practices, perhaps eliminating the current model in which groups cover one hospital or one city alone. In the last three months, Sheridan, the physician services division of AmSurg, Corp has purchased the 60-physician, 140-anesthetist Northside Anesthesiology Consultants in Atlanta, and the 240-physician Valley Anesthesiologists & Pain Consultants in Phoenix. In these purchases, senior board members and partners receive seven-digit checks to sell their practice, then all physicians in the practice’s future labor for a discounted wage, perhaps as low as 50% of the prior income. If this trend becomes widespread, this subset of the anesthesia workforce will become low paid practitioners, while the purchasing corporations will make significant profits for their stockholders.
  10. Continued fascination with anesthesia practice, a discipline which makes all surgical treatments and cures feasible. Without anesthesia, there can be no major surgical procedures. Medical care without major surgical procedures is unthinkable. Whether as anesthesia providers, as patients requiring surgery, or just as observers of the process, we will all continue to value and marvel at the field of anesthesia.

 

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

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

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

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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

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