Saturday, August 30, 2014

Treat Your PONV Patients To A Propofol Sandwich

As any anesthesiologist knows, few things are more uncomfortable for a patient or time consuming for the anesthesiologist as dealing with post operative nausea and vomiting. The surgery and anesthetic may be a complete success but if the patient is puking her guts out in recovery, the goodwill that should have been earned gets flushed into the emesis bag. There are literally dozens of ways that have been attempted to eliminate or at least ameliorate PONV, which only goes to demonstrate how pervasive this problem is. I've been trying a technique called the propofol sandwich that has given me good success.

The propofol sandwich certainly wasn't invented by me. It has been extensively written about and researched. However, I was never taught this in my residency and only first read of its efficacy in a California Society of Anesthesiologists newsletter last year. Written by Orange County anesthesiologist Michael Reines, MD, he describes his technique, which he calls bookending, of finishing his cases by turning off all inhalational agents in the last 15-20 minutes of surgery and substituting small boluses of propofol to maintain amnesia. His goal is to use about the same amount of propofol at the end of the case as was used during induction and to have zero levels of volatile anesthetics in the patient's system by the time she wakes up.

Intrigued, I decided to try this for myself these last few months. This works best for predictable cases like appendectomies or lap choles where if you know the surgeon it is easy to guess how long it will take before the case concludes. It doesn't work quite as well in cases that can finish quickly and unexpectedly like ENT procedures. Unlike Dr. Reines, I use a propofol drip to maintain the sedation instead of giving small boluses. Giving small discreet aliquots of propofol at the end has demonstrated blood levels of the drug that is subtherapeutic and isn't adequate to prevent nausea. Running at a rate of about 100 mcg/kg/min, I can maintain good sedation during the last 20 minutes of surgery while allowing the gases to fall to zero before the patient emerges from anesthesia. The key is having as little volatile agents as possible in the patient by the time she awakens.

Why not just go with a total IV anesthetic using propofol for the entire case? Doing so runs the risk that the patient will take a long time to emerge from the anesthetic. Thanks to their insolubility, gases like desflurane and sevoflurane are expelled very quickly by the body whereas propofol can sometimes take longer than anticipated to metabolize, especially in the elderly or obese. By using a small infusion rate at the end of the case, there is less risk of the propofol accumulating in the patient causing a prolonged emergence. It is also less expensive to give a propofol sandwich than to administer TIVA.

How do I know that the patient isn't aware during the operation running on such a low dose of propofol? Anybody who has ever given sedation in the ICU knows that it doesn't take much propofol to provide amnesia. Also in MAC cases like GI endoscopies, experience has shown that very small amounts of propofol is all that's needed to maintain good amnesia. If you're truly concerned about possible surgical recall, you can first try the propofol sandwich by using a BIS monitor to give yourself some piece of mind. Just remember to keep the patient lightly paralyzed up until the end of the case or the BIS readings will jump with the patient's muscle movements.

With the propofol sandwich, I've found that my patients wake up much more quickly and smoothly than with trying to breathe off the inhalational gases. The patients also don't need as much paralytics to maintain muscle relaxation with propofol. Thus I can reverse the paralysis very readily. And my patients in general seem to have less complaints of PONV. Those who have a history of PONV say they still have some nausea but is less severe than with previous operations.

So try the propofol sandwich on your PONV prone patients. You might be pleasantly surprised by how rapidly they emerge with very little nausea. Then you'll get all the kudos from the patient, her family, and the surgeon for being such a terrific anesthesiologist. You have nothing to lose except your patient's emesis basins. You also might want to pass along where you got your new insight on treating PONV.

Friday, August 29, 2014

Incompetent IV Placement Botches Execution

The autopsy report on Clayton Lockett has been released. Mr. Lockett was the convicted murderer who was executed by the state of Oklahoma back on April 29. The incident made national headlines when the procedure took over 45 minutes to conclude. Witnesses reported that the prisoner was writhing and appeared to be vocalizing pain after the medications were given. At the time, a doctor stated that the IV had blown and they had to start a new one. Ultimately Mr. Lockett died but due to a cardiac arrest.

The autopsy now shows that Mr. Lockett did indeed pass away from the drugs that were administered, not an MI. However, the reason that death took so long was because the drugs had infiltrated into the soft tissue instead passing directly into his blood stream. And it appeared the prison staff tried REALLY hard to get an IV in. Examination of the body showed IVs were attempted in both arms, the neck, the right foot, and both groins. It seems that the femoral veins too were not successfully cannulated which led to the IV infiltration.

The drugs that were given also came to light. They included midazolam, vecuronium, and potassium. While the dosages that were administered were not listed, it would appear that an IM injection of midazolam may not have been sufficient to cause amnesia if they were giving him the usual IV dose. Vecuronium would also have taken a lot longer and need a bigger dose to work in the soft tissue, possibly causing the prolonged movements that were witnessed. And that potassium injection into muscle would have hurt like heck.

Perhaps before the next time the Oklahoma penitentiary system attempts another execution, they should read my advice on how to start a difficult IV. But then again, convicted murderers like these don't deserve much mercy after the harrowing crimes they committed that landed them on that executioner's table in the first place.

Thursday, August 28, 2014

The ASA Is Getting Desperate about CRNA's

I received this email from the ASA the other day. It breathlessly declared, "Nurse anesthetist care not equal to physician anesthesiologist-led care, comprehensive evidence-based review finds." I thought, Whoa! Did the ASA just discover the Holy Grail that will finally demonstrate the superiority of anesthesiologists over CRNA's?

So I dig a little deeper. The ASA is citing a study conducted by the Cochrane Collaboration, a "global independent network of health practitioners, researchers, patient advocates, and others..." The study is called, "Physician anaesthetists versus nurse anaesthetists for surgical patients." It is actually a meta-analysis of six different papers that tried to compare the quality of work of anesthesiologists versus CRNA's. The six articles combined had over 1.5 million patient records. None of these studies were blinded due to ethical and impractical reasons.

After reviewing all the studies, the authors felt that none of the papers could conclusively declare that anesthesiologists or CRNA's gave better care. Some appeared to give the advantage to the nurses while others favored the doctors. But all of them were too flawed to declare the results unequivocal. The studies did not properly account for the different acuity levels of patients that were treated by physicians versus nurses. The different practice locations of the two professionals, Level 1 trauma center vs. rural community hospital, were not adequately taken into consideration. There were large variations in how the papers treated the complication rates.

Ultimately the authors stated that there were just too many variables involved to make a strong statement. They concluded, "it was not possible to say whether there were any differences in care between medically qualified anaesthetists and nurse anaesthetists from the available evidence."

The inability to document the superiority of anesthesiologists versus CRNA's in the final result doesn't exactly conform to the screaming headline the ASA is trying to plaster all over the internet. Is the ASA becoming so desperate in its attempt to disparage the nurses that they will twist a scientific paper to justify its own personal beliefs even if the paper doesn't support that goal in any way?

As anesthesia technology and techniques continue to improve, that objective is going to get even harder. Through rigorous research conducted by physicians, we are constantly striving to improve the safety profile of our field. Then we magnanimously pass along this new knowledge to anesthesia and SRNA residents without prejudice because we believe patient safety is the number one goal of all anesthesia providers regardless of degree. So it's no wonder there will be very little documentable evidence of physician superiority, even though we can feel it through every fiber of our being. The ASA is going to have to try a lot harder than mischaracterizing a research paper to prove to its members that they are in fact number one.

Wednesday, August 27, 2014

Time To Ban Cell Phones In The Operating Room

For decades anesthesiologists were at the forefront in promoting patient safety. From encouraging the use of inventions like the end tidal CO2 monitor to developing the ASA Closed Claims Project to identify potential sources of patient injury, anesthesiologists have rightly been proud of their role in enhancing patient confidence when they enter the hospital.

But now all those years of hard work may be for naught. Thanks to the ubiquity of internet connected devices like smartphones and tablets, anesthesiologists are suddenly being tagged with a reputation for being distracted and inattentive. We have already seen an anesthesiologist in Texas accused of allowing his patient to die under his care because he was too busy posting on Facebook to notice his patient was hypoxic.

In our own institution we are starting to hear more and more surgeons complain about anesthesiologists who are too busy on their electronics to notice that the patient on the operating table is moving, hypotensive, or, in a MAC case, aspirating. Our once sterling reputation for being the patient's advocate while in the OR is slowly becoming a farce.

Anesthesiologists aren't the first professionals to become seduced by the fatal attraction of digital devices. In 2008, a train engineer in Los Angeles was found to be texting right up until he had a head on collision with another train killing 25 people and injuring 135. He himself was killed in the accident. Then there were the two Delta Airlines pilots who were so distracted on their computers that they totally missed their destination and overshot Minneapolis by over 100 miles. Studies have shown that using cellphones while driving is just as dangerous as driving while intoxicated. That's why 44 states ban texting while driving and 12 states ban the handheld use of cellphones.

According to Delta Airlines policy on using electronic devices while flying, "Using laptops or engaging in activity unrelated to the pilots' command of the aircraft during flight is strictly against the airline's flight deck policies and violations of that policy will result in termination." Sounds like words that should be used in formulating OR policies also.

Imagine if you asked your anesthesia colleague to provide the anesthesia for your mother's hip replacement. How would you feel if during the procedure you quickly peeked into the operating room window and saw your friend surfing the net on his tablet? So how do you think families would feel if they knew that their anesthesiologist was reading articles on ESPN.com when he should be watching the patient.

Remember the paranoia we all felt as anesthesia residents? During those early years of training we were terrified that our patient would crump while under our care. Ten times worse if the patient collapses just as the attending walks in. Somewhere along the line we have lost our fear of bad outcomes and decided that anesthesia is so safe that it no longer needs our constant attention. That of course is the fool's errand that will lead us to catastrophe and ruin.

Granted distracted anesthesia rarely causes a fatal event. But it often increases the anesthesiologist's response time to changing patient conditions. If the patient's oxygen saturation starts drifting lower, how likely is the anesthesiologist going to jump on the situation if he is trying to quickly finish up his text? If the blood pressure suddenly shoots up, will the anesthesiologist rapidly administer a treatment if he is engrossed in a game of Flappy Bird? During an operation, seconds count. That's why we love all the real time monitors that are now available to us, unlike the old days of feeling for a patient's pulse every 3-5 minutes. But what good is all this monitoring if we don't respond to the information that is given to us?

Therefore I think a ban on smartphone and tablet use should be considered for operating rooms. There are too many instances of these machines causing harm in the workplace and zero cases of it helping. "But what if my son was in an emergency and needed to call me right away?" Well, how would you handle that situation a decade ago? Back then smart devices were not so plentiful and yet we all survived the era before iPhones became popular. There is still the operating room and hospital phones that can reach you for emergencies. Pagers are still commonly found.

Now I am no angel myself when it comes to using electronic devices while working. While I try to minimize the amount of time I'm on the internet, invariably a case will become prolonged and the temptation to sneak a peek at my phone becomes too great to overcome. That quick look soon becomes a lengthy review of emails, text messages, news sites and other activities that pulls me away from my patient and the case at hand. Before I know it the surgeon is screaming, "Anesthesia, the patient is waking up!" and I realize I hadn't redosed the paralytic in some time.

Perhaps a total ban on cellphones is too draconian. How about trying just one or two days a week without the phone to get yourself reacquainted with actually monitoring your patients. It doesn't even have to be the whole day. Looking at the phone between cases is acceptable. But from the time a patient rolls into the operating room to the time you drop him off in recovery, the phone should stay in your pocket or bag. It will not be the end of the world.

If we anesthesiologists don't get our acts together on this, somebody else will. Either the ASA will be forced to issue a standard of care guideline regarding electronics devices in the operating room or the government will pass down laws similar to the driving while texting laws. Then something as simple as answering a text in the operating room could become a criminal offense. We would only have our own impropriety to blame.

Tuesday, August 26, 2014

Not All Anesthesia Is General. Duh.

Here is a headline from the Dallas Morning News that seems to describe a miraculous new technique for providing anesthesia, "Would you give up anesthesia for hypnosis?" The article starts off by teasing what seemed to be the impossible, and the death of anesthesiology, "Bob Dick recently toughed his way through a 90-minute total knee replacement without the aid of anesthesia, choosing to stay awake through the chisel and the buzz of the electric saw."

Uh oh, I thought. Were all those years of anesthesia residency for naught when a patient can go through a highly invasive procedure like a knee replacement without my intervention? The paper describes the psychologist's technique for surviving such an operation, "he started breathing deeply, a signal for his body to relax. Next he held his thumb and forefinger together, imagining a walk around the pond at his home." Wow! Is that all there is to it to avoid pain during an operation?

It is not until later in the article does the truth about his new anesthesia replacement come to light. It seems that Dr. Dick had received "nerve blockers" to take away the trauma of the operation. But he doesn't give any credit at all to his anesthesiologist. Instead he gives himself a pat on the back with his self-hypnosis technique, "It's the closest thing to magic I know. I knew it was there. I just wasn't paying attention to it."

He goes on to describe how he was able to undergo a colonoscopy using the same hypnosis approach. Except this time it wasn't as successful because that darn gastroenterologist kept disrupting his trance by asking if he was in any pain.

Dr. Dick, before you start broadcasting to the whole world what a ludicrous claim you are making about self hypnosis as an anesthetic technique, please familiarize yourself first with something called regional anesthesia. It's only been around for a century or so. We anesthesiologists do it every day for orthopedic procedures like yours. Yes our patients also feel no pain. They too can stay awake if they prefer. But most of our patients would rather have a light sedation like some Versed so they don't have to listen to the sounds of the operating room. See our patients normally aren't as proficient at hypnotizing themselves as you are. As far as the colonoscopy is concerned, millions of people undergo colonoscopies without any sedation. And they don't have to put themselves into a stupor to do so. That's called toughing it out. Or some people would prefer to say they are taking the scenic view of their colons.

Perhaps the reporter can also do a little more in-depth research on regional anesthesia instead of just regurgitating some sort of feel good public relations fantasy. Here is an informative page from the American Society of Regional Anesthesia and Pain Medicine. And it only took a single Google search to find it. But I guess that would be too much work for a journalist in the Lifestyle section of the paper.

Friday, August 22, 2014

Is The Anesthesia Job Market Saturated?

Merritt Hawkins, the physician placement firm, has released its 2014 list of doctors in highest demand in the community. For the seventh year in a row, to no one's surprise, family medicine and other primary care fields were requested over all others. Most of the jobs in the top ten belonged to PCP's or physician extenders like PA's and NP's. It's not until the bottom half of this top twenty list do you start seeing need for specialty fields like surgery or cardiology.

I was a little surprised that anesthesiologists were not on this list of sought after doctors. It wasn't that long ago that the ASA loudly proclaimed the U.S. has a shortfall of several thousand anesthesiologists and that this situation will only get worse through the rest of the decade. If anesthesiologists are supposedly in such shortage, how come we don't see that reflected in the jobs marketplace?

In the early years of the last decade, radiology and anesthesiology were frequently the highest requested physicians in the Merritt Hawkins surveys. But starting in 2005, M-H already started noticing a downturn in demand for these two ROAD fields. In its report that year, anesthesiology had dropped to the tenth spot. The company wrote in the report, "anesthesiology is one of the few medical specialties where a significant amount of care can be provided by non-physicians, and in many cases health care organizations are recruiting certified registered nurse anesthetists (CRNA's) in lieu of anesthesiologists."

The picture continued to grow more bleak as the decade progressed. In the 2009 survey, anesthesiology placement had dropped to 19th place, with CRNA just slightly higher at 18th. Then in Merritt Hawkins's 2012 report, the bottom finally fell out of the specialty. That year M-H stated that, "for the first time since Merritt Hawkins began compiling data for this Review, anesthesiology was not among its top 20 most requested search assignments." It has not made a reappearance in the top twenty list since. In this year's report, M-H theorized that, "Inhibiting demand for anesthesiologists is the use of certified nurse anesthetists (CRNAs), who now administer 65% of all anesthetics nationwide, according to the American Association of Nurse Anesthetists (AANA) and are particularly prevalent in smaller, rural communities."

So who are you going to believe, the ASA with its interest in self promotion, or a third party company who is reading the pulse of the jobs market on a daily basis? If you peruse the job listings in the anesthesiology jobs site GasWork, you can see that many states have few posts available. And the anesthesiologists that are requested are for very specific subspecialties like cardiac or OB anesthesia or for part time locums positions.

Are we in another downturn in the anesthesia market like the mid 1990's? Back then you couldn't give away anesthesia residency spots. No smart medical student wanted to go into a dead end residency with such a poor job prospect like anesthesiology. But soon the cycle turned and anesthesiologists experienced a boom in demand as a dearth of new anesthesia graduates were unable to fill all the job openings available. Has the bubble already popped in anesthesiology? Only time will tell.

Thursday, August 21, 2014

Cheapskate Anesthesiologists

On August 13, ASAPAC, the political action committee of the ASA, held a 24 hour marathon to try to raise $100,000 from its members to cover a shortfall in contributions this fiscal year. All day ASA members were bombarded with urgent emails imploring us to make any monetary donations. The state with the most contributors would even get a special mention in ASAPAC publications. Woohoo!

Now you would think that raising $100,000 from a group of anesthesiologists should be relatively easy. First of all, the ASA boasts over 50,000 members in its ranks. Then you consider that the average salary of an anesthesiologist is $338,000. Right there we're talking about almost $17 BILLION of earnings power to forward our society's political agenda. So raising a measly $100K shouldn't be that hard, right?

Well, yes and no. Yes the ASAPAC did reach its fundraising goal of $100,000. As a matter of fact, they raised $195,304. So the society got almost twice what it was looking for, giving a healthy boost towards next year's contributions already. But it was the manner in which it was raised that is shameful.

Out of 50,000 ASA members, just 867 of them decided to open their wallets a little bit to help their profession further its causes, like opposing the new VA Nurses Handbook or demanding Medicare reimbursement equivalency with other physicians. That is not even two percent of the membership that could be bothered to help out their own future.

The state with the most contributors was California, with eighty. That should not be a surprise since California has the most ASA members. However California anesthesiologists gave on average a paltry $179.37 each. That is below the national average donation of $225.26. Full disclosure--I too donated to the ASAPAC that day. Alabama took the prize for most money given per physician. Its 46 donors gave a mean of $503.70. At least we didn't bring up the bottom of the list. Ironically that dubious honor belongs to the anesthesiologists in the District of Columbia. They of all ASA members should realize how important money is to get any traction with our nation's representatives. D.C.'s five anesthesiologist donors only contributed a mere $73.33 each. That's just pathetic.

So congratulations to the ASA and the ASAPAC for making your goal this year. We need our voices heard loud and clear in Washington to make sure anesthesiologists remain a formidable presence in all healthcare related legislation. However I think a stronger outreach needs to be undertaken to get members more heavily invested in the society. When 98% of the members choose to ignore an urgent plea to contribute to their own professional future, the membership is telling the society that they don't feel they are getting their voices heard inside the new glass headquarters up there in Schaumberg.