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

 

 

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

 

 

DO YOU NEED AN ANESTHESIOLOGIST FOR A COLONOSCOPY?

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)

Do you need an anesthesiologist for a colonoscopy?  The answer is:  it depends.

It depends on 1) your health, 2) the conscious sedation skills of your gastroenterologist, and 3) the facility you have your colonoscopy at.

1)  YOUR HEALTH. The majority of colonoscopies in the United States are performed under conscious sedation.  Conscious sedation is administered by a registered nurse, under specific orders from the gastroenterologist.  The typical drugs are Versed (midazolam) and fentanyl.  Versed is a benzodiazepine, or Valium-like medication, that is superb in reducing anxiety, sleepiness, and producing amnesia.  Fentanyl is a narcotic pain reliever, similar to a short-acting morphine.  The combination of these two types of medications renders a patient sleepy but awake.  Most patients can minimal or no recollection of the colonoscopy procedure when under the influence of these two drugs.  I can speak from personal experience, as I had a colonoscopy myself, with conscious sedation with Versed and fentanyl, and I remembered nothing of the procedure.

If you are a reasonably healthy adult, you should be fine having the procedure under conscious sedation.  Patients with high blood pressure, diabetes, asthma, obesity, mild to moderate sleep apnea, advanced age, or stable cardiac disease are have conscious sedation for colonoscopies in America every day, without significant complications.

Certain patients are not good candidates for conscious sedation, and require an anesthesiologist for sedation or general anesthesia.  Included in this category are a) patients on large doses of chronic narcotics for chronic pain, who are tolerant to the fentanyl and are therefore difficult to sedate, b) certain patients with morbid obesity, c) certain patients with severe sleep apnea, and d) certain patients with severe heart or breathing problems.

2)  THE CONSCIOUS SEDATION SKILLS OF YOUR GASTROENTEROLOGIST.  Most gastroenterologists are comfortable directing registered nurses in the administration of conscious sedation drugs.  Some, however, are not.  These gastroenterologists will disclose this to their patients, and recommend that an anesthesiologist administer general anesthesia for the procedure.

3) THE FACILITY YOU HAVE YOUR COLONOSCOPY AT.  Most endoscopy facilities have nurses and gastroenterologists comfortable with conscious sedation.  Some do not.  The facility you are referred to may have a consistent policy of having an anesthesiologist administer general anesthesia with propofol for all colonoscopies.  If this is true, they should disclose this to you, the patient, before you start your bowel prep for the procedure.  A facility which always utilizes general anesthesia means that you, the patient, will incur one extra physician bill for your procedure, from an anesthesiologist.

I refer you to an article from the New York Times, which summarizes this phenomenon in the New York region:

One last point: If the drugs Versed and fentanyl are used, there exist specific and effective antidotes for each drug if the patient becomes oversedated. The antagonist for Versed is Romazicon (flumazenil), and the antagonist for fentanyl is Narcan (naloxone). If these drugs are injected promptly into the IV of an oversedated patient, the patient will wake up in seconds, before any oxygen deprivation affects the brain or heart.

Propofol, however, has no specific antagonist. Propofol only wears off as it is redistributed out of the blood stream into other tissues, and its blood level declines. A propofol overdose can cause obstruction of breathing, and/or depression of breathing, such that the blood oxygen level is insufficient for the brain and heart. The Food and Drug Administration (FDA) mandates that a Black Box warning be included in the packaging of every box of propofol. That warning states that propofol “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.”

Anesthesiologists are experts at using propofol. I administer propofol to 99% of my patients who are undergoing general anesthesia for a surgical procedure. Anesthesiologists are experts at managing airways and breathing. Individuals who are not trained to administer general anesthesia should never administer propofol to a patient, in a hospital or in an outpatient surgery center.

I serve as the Medical Director of an outpatient surgery center in Palo Alto, California. We perform a variety of orthopedic, head and neck, plastic, ophthalmic, and general surgery procedures safely each year. In addition, our gastroenterologists perform thousands of endoscopies each year. I review the charts of the endoscopy patients as well as the surgical patients prior to the procedures, and in our center, approximately 99% of endoscopies can be safely performed under Versed and fentanyl conscious sedation, without the need for an anesthesiologist attending to the patient.

If you have an endoscopy, ask questions. Will you receive conscious sedation with drugs like Versed and fentanyl, or will an anesthesiology professional administer propofol? You deserve to know.

 

 

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

 

 

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