Sunday, October 9, 2005

I Am A Propofologist

I've decided to change my title from 'Anesthesiologist' to the more descriptive 'Propofologist.' Maybe it's because I've been doing lots of sedation for colonoscopies and esophagogastroduodenoscopies (EGD) for which I use propofol/lidocaine only. When someone asks for anesthesia services, especially outside the operating room, what they're really asking for is someone who can give propofol to the point of loss of consciousness--hence the (new) term. Your heard it here first.

Monday, August 22, 2005

NYT: Sick and Scared, and Waiting, Waiting, Waiting

NYT: Sick and Scared, and Waiting, Waiting, Waiting

Medicine from the patient's side. A must read article no matter what specialty you're in.

Saturday, April 23, 2005

When can nursing mothers resume breastfeeding after surgery?

When can nursing mothers resume breastfeeding after surgery?:

" the very small amount of propofol eliminated in breast milk within the first 24 hours after induction of anesthesia represents such minimal infant exposure to the drug that it provides insufficient justification for interruption of breastfeeding, Avram said. "

Studies are under way by the same group for other commonly used drugs. My advice to nursing patients is to pump and discard once, then resume normal breast feeding.

Wednesday, March 23, 2005

C. difficile Outbreaks, Anyone?

Our hospital has pulled all 3M Avagard hand disinfectant from the operating rooms, preferring instead that surgeons go back to the old fashioned surgical hand scrub. At the same time, we are apparently seeing more nosocomial Clostridium difficile infections. C. diff. is not a reportable pathogen, and this was felt to contribute to the outbreak Canada experienced recently. Avagard does not inactivate C. diff. spores. Co-incidence? I don't think so.

The CDC page for healthcare providers on C. diff. provides an interesting nugget:

"If your institution experiences an outbreak, consider using only soap and water for hand hygiene when caring for patients with Clostridium difficile-associated disease; alcohol-based hand rubs may not be as effective against spore-forming bacteria."

Has anyone else seen this at their facilities?

Saturday, March 12, 2005

Obstetrical deaths in the UK--Anesthesia component

Why Mothers Die 2000-2002 - Report on confidential enquiries into maternal deaths in the United Kingdom

Chapter 9--Anaesthesia

The anesthesia chapter concludes:

"The management of haemorrhage is a shared responsibility of midwifery, obstetric, anaesthetic and blood transfusion personnel. Anaesthetists should be ready to suggest that the obstetrician summons help in the face of major haemorrhage regardless of the obstetrician’s grade or experience. Good communication is vital and regular practice of emergency drills is crucial, particularly in units with a high turnover of staff."

I would like to think that many of the problems pointed out in this report would not happen in the United States, but that would be intellectually dishonest. If you provide anesthesia for obstetrical patients as I do, it's worth reading over this report for the lessons that are applicable in the US.

Wednesday, March 9, 2005

"If you're wrong, I'll sue you."

That's what the patient was overheard to say after I finished a discussion with her about why she would not need prophylactic antibiotics before a nasal procedure. Her medical history was significant only for a 'heart murmur' (which I could not auscultate). No workup or echocardiogram had been done to rule in a structural cardiac abnormality. The patient denied signs or symptoms of valvular heart disease including mitral valve prolapse, and had a very good exercise tolerance. I quoted the AHA Recommendations which, it turns out, admit that....

"There are currently no randomized and carefully controlled human trials in patients with underlying structural heart disease to definitively establish that antibiotic prophylaxis provides protection against development of endocarditis during bacteremia-inducing procedures. Further, most cases of endocarditis are not attributable to an invasive procedure. "

"If you're wrong, I'll sue you" was reportedly spoken by the patient after I had left the bedside. As I saw it, I had three choices:

  1. Tell her I would not provide her an anesthetic for this elective surgery as she had revealed herself to be a litigious patient.
  2. Reschedule her surgery after an echocardiogram had been performed to elucidate the origin of the murmur.
  3. Give her the antibiotic and get on with things.

Part of why I had such a strong emotional reaction upon hearing this was almost certainly because I have been in practice over eight nearly nine years and have yet to be named in a suit (the average physician is sued once every eight years). And because some very talented surgeons have left Pennsylvania because of the malpractice environment (and have been replaced by considerably less talented surgeons).

After I talked it over with the surgeon (who asked me to proceed so as not to put him in a difficult position) I gave her the antibiotic and got on with things...but not until after I had listed for her every possible complication of both the antibiotic dose and the anesthetic she was about to receive, including brain damage and death.

Now, all the informed consent in the world isn't going to stop a patient from suing regardless of outcome if they want to sue. I decided to save my charm, humor, and best bedside manner for patients that have the good sense not to talk about bombs while they're waiting in line at airport security.

Tuesday, March 1, 2005

Discovery Health: Anesthesia (Reporting) Nightmares

I watched 'Anesthesia Nightmares' on the Discovery Health channel last night (listing). As an anesthesiologist, the awareness and recall of surgery are of grave concern to me, so I tuned in for what I hoped would be an informative, informed, hour of Discovery Health television. What I saw amounted to fearmongering.

Let me state at the outset that I do not doubt the ordeals described by the victims interviewed in the show. Awareness and recall under anesthesia happen. How often they happen has recently been answered by an article titled The incidence of awareness during anesthesia: a multicenter United States study. The study was funded by the company that makes depth of anesthesia monitors (Aspect), but I can't find fault with their data:

" Assuming that approximately 20 million anesthetics are administered in the United States annually, we can expect approximately 26,000 cases to occur each year. "

Before I point out some of the specific information I disagree with, let me make a few general points.

I. Not every occurrence of awareness is the kind of 'anesthesia nightmare' described in the show. This should have been pointed out during the report. From the article referenced above:

Summary of Awareness Descriptions (n = 25)

Auditory perceptions 12 48
Unable to move or breathe 12 48
Anxiety/stress 9 36
Pain 7 28
Sensation of endotracheal tube 6 24
Feeling surgery without pain 2 8

More than one description may occur per case.

II. We know the risk of awareness is higher in certain kinds of operations (trauma resuscitations, open heart surgery, and emergency cesarean sections are three that come to mind) and in certain kinds of patients (patient with significant coexisting medical conditions such as heart disease or renal failure). In those cases there is a trade-off between depth of anesthesia and patient well-being. There can also be awareness during an unanticipated difficult airway (the first dose of injected anesthetic begins to wear off before the inhaled anesthetic is started.

III. We sometimes are asked to do anesthetics which would not be our first choice. Certain orthopedic spine procedures require special monitoring which is in turn affected by anesthetic levels. We have to modify our preferred anesthetic to take into account this new requirement--and the risk of awareness is higher if we can't use inhaled agents, for example.

Let me now give some quotes from the show that I think are misleading and explain why I think so:

Narrator: "The gas was not working, but like all surgical patients, Joe had also been given a paralytic drug"

This is false. Most surgical patients do not receive a paralytic drug. Intra-abdominal, intrathoracic, intracranial cases do because the surgery could not be done without them, but that's not a majority of cases. We try to avoid giving paralytics unless they're clearly indicated.

Dr. Frank Sweeny: "There are a variety of theories about what anesthesia is, but really I can summarize it in three words: We Don't Know"

This is simply a poor choice of words on Dr. Sweeny's part or Discovery Health taking it his quote out of context. Although it is true we do not precisely understand the mechanisms of some anesthetics, we do know a great deal about how these drugs work as evidenced by the safe and uneventful conduct of the vast majority of anesthetics given each day.

Narrator: "Anesthesiologists have to find a delicate balance between three types of drugs: paralytics to prevent movement, analgesics to dull pain, and narcotics to induce unconsciousness"

Well, not quite. Anesthesiologist seek a balance between drugs that cause unconsciousness, amnesia, anxiolysis, attenuation of the stress response, and muscle relaxation (for a history, see this article). Narcotics are used to block pain and therefore attenuate the stress response (but so do drugs like beta blockers). Narcotics do not induce unconsciousness (very well). We use inhaled anesthetics (such successors to ether) and intravenous anesthetics (such as successors to sodium pentothal) for that. It is this line that makes me think that the creators of this show did not allow an anesthesiologist to screen the final product for accuracy.

Narrator: "What no one in the operating room realized is that the canisters of anesthetic gas were empty"

This can happen, but if the pre-anesthetic checklist is used properly, it won't. Checking anesthetic levels is on the checklist. In addition, one of our inhaled anesthetics (Desflurane) has a vaporizer with a built-in alarm for when the anesthetic level gets low that can then be refilled without having to turn the vaporizer off (thus eliminating the risk of forgetting to turn the vaporizer back on).

Narrator: "A muscle relaxant is used to keep the body still during surgery"

A muscle relaxant is used to relax (paralyze) the muscles. We keep the patient still by making sure they are sufficiently anesthetized. Reflexly giving more paralytic if a patient moves is the wrong response. First insure lack of awareness, lack of pain, adequate anesthetic levels, then consider re-dosing the muscle relaxant.

Narrator: "Studies have shown that mistakes happen in 3% of all operations."

That may be true, but it's far too vague to have any bearing here. Mistakes by whom? Of what magnitude? Did harm actually come to the patient?

Finally the show introduces the brain monitor called Bis (for Bispectral Index), and the person introducing it is a Dr. Don Mathews. What the series does not indicate is that Dr. Mathews is on the speakers buereau for Aspect medical, maker of the Bis monitor. Dr. Mathews narrates a case where the patient actually requires less anesthesia than he thought--and that's exactly my experience with the Bis monitor. After using it for several years, I have never deepened someone's anesthetic because of what the monitor showed, only lightened it. The Bis monitor, and others like it, is being studies intensely in the literature, but I don't think there's a consensus yet. Bis measures level of hypnosis. Not depth of anesthesia. Using Bis makes no difference in the incidence of painful awareness.

It's late and I want to get this posted, but reserve the right to add a Part II should the urge arise.

For more information, see the JCAHO Sentinel Event Alert on "Preventing, and managing the impact of, anesthesia awareness" published in October 2004.

Wednesday, February 16, 2005

NEJM -- The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor

NEJM --The Risk of Cesarean Delivery with Neuraxial Analgesia Given Early versus Late in Labor

" Analgesia was initiated in the intrathecal group by a combined spinal–epidural technique. Intrathecal fentanyl (25 µg) was injected, an epidural catheter placed, and an epidural test dose administered. At the second request for analgesia, the cervix was again examined. Epidural analgesia was then initiated as follows: if the cervix was less than 4.0 cm in diameter, a 15-ml epidural bolus of bupivacaine (0.625 mg per milliliter) with fentanyl (2 µg per milliliter) was given, and if the cervix was 4.0 cm or greater in diameter, a 15-ml epidural bolus of bupivacaine (1.25 mg per milliliter) was given (Figure 1). In both instances, patient-controlled epidural analgesia was then begun. "

Bottom Line: Intrathecal fentanyl in women not yet at 4 cm cervical dilation does not increase C-section rate when compared to systemic opioids. Lots of great information to digest over the next several days...

Sunday, February 13, 2005

Think CPAP Mask After Major Abdominal Surgery

JAMA just published Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial and those of us giving anesthesia for open major abdominal surgery should take note. Here's the abstract:

" Results Patients who received oxygen plus continuous positive airway pressure had a lower intubation rate (1% vs 10%; P = .005; relative risk [RR], 0.099; 95% confidence interval [CI], 0.01-0.76) and had a lower occurrence rate of pneumonia (2% vs 10%, RR, 0.19; 95% CI, 0.04-0.88; P = .02), infection (3% vs 10%, RR, 0.27; 95% CI, 0.07-0.94; P = .03), and sepsis (2% vs 9%; RR, 0.22; 95% CI, 0.04-0.99; P = .03) than did patients treated with oxygen alone. Patients who received oxygen plus continuous positive airway pressure also spent fewer mean (SD) days in the intensive care unit (1.4 [1.6] vs 2.6 [4.2], P = .09) than patients treated with oxygen alone. The treatments did not affect the mean (SD) days that patients spent in the hospital (15 [13] vs 17 [15], respectively; P = .10). None of those treated with oxygen plus continuous positive airway pressure died in the hospital while 3 deaths occurred among those treated with oxygen alone (P = .12). "

I remember the first time someone suggested using CPAP for the struggling patient in the recovery room after major abdominal surgery. I snorted and mumbled something under my breath about how the patient needed an endotracheal tube and should have taken the offered thoracic epidural. I went back to bed, convinced that I'd be called in an hour or two to intubate the patient who would by then certainly be in extremis. You know what? They never called me that night and this paper helps me understand why.

I think I need to modify my internal algorithm for post-anesthesia management of these often difficult cases to reflect the option of CPAP as a middle ground between mask oxygen and endotracheal intubation.

Screening for AAA Recommended for Smokers Aged 65-75

The U.S. Preventive Services Task Force (part of AHRQ) now 'recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.'

" Rationale: The USPSTF found good evidence that screening for AAA and surgical repair of large AAAs (5.5 cm or more) in men aged 65 to 75 who have ever smoked (current and former smokers) leads to decreased AAA-specific mortality. There is good evidence that abdominal ultrasonography, performed in a setting with adequate quality assurance (i.e., in an accredited facility with credentialed technologists), is an accurate screening test for AAA. There is also good evidence of important harms of screening and early treatment, including an increased number of surgeries with associated clinically-significant morbidity and mortality, and short-term psychological harms. Based on the moderate magnitude of net benefit, the USPSTF concluded that the benefits of screening for AAA in men aged 65 to 75 who have ever smoked outweigh the harms. "

Patients should also be made aware that there is an alternative to open AAA repairs known as 'endovascular repair.' NEJM recently published A Randomized Trial Comparing Conventional and Endovascular Repair of Abdominal Aortic Aneurysms which concluded:

" On the basis of the overall results of this trial, endovascular repair is preferable to open repair in patients who have an abdominal aortic aneurysm that is at least 5 cm in diameter. Long-term follow-up is needed to determine whether this advantage is sustained. "

As an aside, wouldn't it be nice to be able to query our electronic medical record for all patients in our primary care practice who meet this criteria? Oh wait. We don't have EMR's (for the most part).

Friday, December 10, 2004

Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials -- Colman et al. 329 (7479): 1369 -- BMJ

BMJ: Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials -- Colman et al. 329 (7479): 1369

""Conclusions: Metoclopramide is an effective treatment for migraine headache and may be effective when combined with other treatments. Given its non-narcotic and antiemetic properties, metoclopramide should be considered a primary agent in the treatment of acute migraines in emergency departments.""

This works well. I've been using metoclopramide (Reglan) for perioperative migraine for years, ever since learning about it from a Navy ER doc at Balboa. I don't use metoclopramide for post-operative nausea vomiting (prophylactic or treatment), but that's another blog post.

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