Monthly Archives: October 2014

Recommendations from the American Society of Anesthesiologists Ebola Workgroup

The American Society of Anesthesiologists recently published recommendations for treating patients with ebola:

https://www.asahq.org/For-Members/Clinical-Information/Ebola-Information/Ebola-Guidelines-from-COH.aspx.

Also, it has answered frequently asked questions:

https://www.asahq.org/For-Members/Clinical-Information/Ebola-Information/Ebola-FAQs.aspx

The death of Joan Rivers

The sudden passing of Joan Rivers during a routine outpatient procedure is tragic. While the events leading to her death have not been fully revealed, the information leaked or released is enough to draw some conclusions and learn from this terrible outcome. Formally reviewing cases in this manner typically takes place during morbidity and mortality (M&M) conferences, a tradition in the modern practice of medicine. The goal of these conferences is to learn from and change behaviors which led to complications or errors rather than to assign blame. Certainly we do not want to be critical of our colleagues who have the tremendous responsibility of caring for their patients daily, particularly since many facts are not known.

Within our specialty, the American Society of Anesthesiology (ASA) maintains a Closed Claims Database that collects information about adverse outcomes that may reveal systemic patterns of problems that, in isolation, would otherwise be difficult to discern.

What has been reported?

Ms. Rivers complained of acid reflux and worsening hoarseness. She visited Yorkville Endoscopy for an outpatient upper endoscopy, a procedure that uses a tube with a camera, to examine the upper portion of the gastrointestinal tract with her gastroenterologist, Dr. Lawrence Cohen. He invited Dr. Gwen Korovin, a private otolaryngologist to perform a laryngoscopy, a procedure using a similar instrument to visualize the vocal cords. Ms. Rivers developed a hypoxic cardiac arrest during the course of her treatment and then died the following week. It was later learned that Dr. Korovin did not have Ms. Rivers’ consent or privileges to work at the clinic.

What most likely happened?

The most likely cause of hypoxia, where the body is deprived of oxygen, is laryngospasm of the vocal cords. The vocal cords are exquisitely sensitive and easily irritated to prevent foreign matter from entering the lungs. In this case, saliva or touching the vocal cords with a scope can precipitate the closure of the vocal cords, or laryngospasm, and prevent air from entering the lungs and supplying the brain, heart, and other organs with oxygen.

Another cause is respiratory depression from administering increasing amounts of anesthetics, such as propofol—to keep a patient sedated or deeply asleep—opoids, and benzodiazepines.

What could have prevented this complication?

The treatment of the problem depends on the cause:

• Positive pressure ventilation with a manual resuscitation bag and face-mask or succinylcholine, a medication that can cause relaxation of the vocal cords, can restore a patent airway in the case of laryngospasm. Alternatively, the trachea can be intubated ahead of time to prevent laryngospasm during the procedure, but laryngospasm can also occur when the tube is removed at the end of the procedure.
• For respiratory depression, the patient could be supplemented with oxygen and airway devices or an antidote can be given for some of the medications to reverse their effects.

What does it mean that Dr. Korovin was not authorized to work in the clinic, even though she was invited to be present?

In order to work in a health care facility, the physician must have their medical credentials reviewed and be granted privileges to work at a center. The idea is to verify that an individual has the proper education, training, and experience. Additionally, the individual’s malpractice history should be reviewed to assess the ability of the health care practitioner to provide acceptable care.

What does it mean that Dr. Korovin did not have consent to perform the procedure?

Competent adult patients must give their physicians permission to perform a procedure on them through a formal process known as informed consent. In it, the physician is supposed to explain the risks, benefits, and alternatives of a procedure. While it is almost impossible to exhaustively discuss every possible risk, the discussion should include the most common and most serious complications such as heart attack, stroke, or death. The patient then must agree to the procedure. In the absence of it, the physician commits battery on the patient if a procedure is performed without proper consent. Patients of sound mind—that is to say they do not suffer from psychiatric disorders or effects of medications that impair judgment—have the right to refuse a procedure, even if it may be life-saving.

Is there any systematic method for ensuring that steps are not missed when a procedure is performed?

The World Health Organization has published a framework to ensure that the necessary steps are followed throughout a procedure.

Before induction of anesthesia

• Has the patient confirmed his/her identity, site, procedure, and consent?
• Is the site marked?
• Is the anesthesia machine and medication check complete?
• Is the pulse oximeter on the patient and functioning?
• Does the patient have a known allergy, difficult airway or aspiration risk, risk of >500ml blood loss (7ml/kg in children)?

Before skin incision

• Confirm all team members have introduced themselves by name and role.
• Confirm the patient’s name, procedure, and where the incision will be made.
• Has antibiotic prophylaxis been given within the last 60 minutes?

Anticipated Critical Events

To Surgeon:

• What are the critical or non-routine steps?
• How long will the case take?
• What is the anticipated blood loss?

To Anesthetist:

• Are there any patient-specific concerns?

To Nursing Team:

• Has sterility (including indicator results) been confirmed?
• Are there equipment issues or any concerns?
• Is essential imaging displayed?

Before patient leaves operating room

Nurse Verbally Confirms:

• The name of the procedure
• Completion of instrument, sponge and needle counts
• Specimen labelling (read specimen labels aloud, including patient name)
• Whether there are any equipment problems to be addressed

To Surgeon, Anesthetist and Nurse:

• What are the key concerns for recovery and management of this patient?

References
1. Barash P, Cullen B, Stoelting R, et al., eds. Clinical Anesthesia. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins.

2. Hartocollis, A. (9 September 2014). “Doctor Present at Joan Rivers’s Procedure Wasn’t Authorized at Clinic”. The New York Times. Retrieved at http://www.nytimes.com/2014/09/12/nyregion/doctor-present-at-joan-riverss-procedure-was-not-authorized-at-clinic.html on 9 October 2014.

3. Hartocollis, A. Goodman JD. (9 September 2014). “At Surgery Clinic, Rush to Save Joan Rivers’s Life”. The New York Times. Retrieved at http://www.nytimes.com/2014/09/10/nyregion/at-east-side-surgery-center-a-rush-to-save-joan-rivers.html?action=click&contentCollection=N.Y.%20%2F%20Region&module=RelatedCoverage&region=Marginalia&pgtype=article on 9 October 2014.

4. Miller RD, Eriksson LI, Fleisher L, et al., eds. Miller’s Anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone.

5. World Health Organization. 2009. Implementation manual WHO surgical safety checklist 2009Safe surgery saves lives. Geneva, Switzerland. Retrieved at http://whqlibdoc.who.int/publications/2009/9789241598590_eng.pdf on 15 October 2014.

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We are physician anesthesiologists (medical doctor / MD) who provide anesthesia to individuals with a phobia, fear, and anxiety for outpatient procedures in fields such as dermatology, plastic surgery, gastroenterology (upper gastrointestinal endoscopy, esophagogastroduodenoscopy, EGD, colonoscopy, otolaryngology (ear, nose, throat / ENT), and dentistry (deep cleaning, implant, all-on-four, root canal, and wisdom teeth extraction).

We provide various levels of anesthesia–from monitored anesthesia care (MAC) to general anesthesia. MAC is often used interchangeably with conscious sedation and twilight anesthesia. As it relates to dentistry, it is referred to as sleep dentistry, sedation dentistry, dental anesthesia, and intravenous, or IV, sedation.

We practice in Northern (Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, and Sonoma counties) and Southern (Los Angeles, Orange, San Bernardino, Riverside, Ventura, and San Diego counties) California.

Are you going to use propofol?

One of the questions we are frequently asked by patients is what type of medications they will be getting during their procedure. Often the answer includes mentioning propofol, or Diprivan, which is the brand name. When some patients hear that they let out a nervous laughter, which is followed by another question: “Isn’t that the same stuff Michael Jackson used?”

“Yes,” I reply. Propofol is used very commonly in many anesthetics and, in the hands of an experienced anesthesiologist, is safe.

The sedative properties of propofol take effect and wear off quickly, which makes it a good choice for outpatient anesthesia for procedures in gastroenterology and dentistry. The medication can be titrated to cause what is commonly known as minimal, moderate, and deep sedation and general anesthesia. Patients report a sense of well-being upon awakening as though they had restful sleep. It also works as an anti-emetic medication to treat nausea or vomiting, which may occur after general anesthesia. If propofol is given as the primary anesthetic, most patients do not experience nausea or vomiting.

Propofol has a sound safety profile, particularly when used by the appropriate healthcare professional where emergencies can be addressed quickly. The concerns of using it:

• may cause pain on injection, but this can be managed with other medications;
• contains sodium sulfide and egg phosphatide, which may cause an allergic reaction in patients sensitive to sulfite or eggs, respectively, but these do not appear to be clinically significant;
• is prepared as a fat emulsion which contributes to the growth of microorganisms and contamination can result but is not a serious problem if it is not used after its expiration time or shared between patients;
• causes cardiovascular and respiratory depression but can be managed by the anesthesiologist; and
• may cause propofol infusion syndrome, which is a constellation of conditions including cardiac and kidney failure but is most common if used in high doses over long periods of time.

There are several major differences to the anesthesiologist’s use of propofol in an outpatient setting compared to that in a home for so-called off-label usage for anxiety or insomnia, or sleeping problems. We use propofol in a setting that is equipped with necessary and backup equipment including oxygen and multiple devices to administer this medication safely.

Other differences are that we:

• use propofol every day for a very brief period of time for patients–only as long as it takes to do the procedure–which is typically no more than a few hours;
• monitor our patients for cardiac, circulatory, and respiratory functions, which include auscultation, or listening, of heart and breath sounds, pulse oximetry for measuring oxygen saturation, capnography to confirm ventilation, electrocardiogram, blood pressure, and temperature;
• administer propofol with an infusion pump, which gives us computer-like precision to give just enough necessary for the patient and no more; and
• are by the patient’s side at all times and often stand in order to increase our situational awareness and give our undivided attention.

There are alternatives to the use of propofol. Please feel free to contact us to discuss this medication further or to request alternatives to propofol.

References

1. Barash P, Cullen B, Stoelting R, et al., eds. Clinical Anesthesia. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins.

2. Death Certificate for Michael Jackson, 25 June 2009, File No. 3052009085414, Los Angeles County Department of Health Services.

3. Miller RD, Eriksson LI, Fleisher L, et al., eds. Miller’s Anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone.

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We are physician anesthesiologists (medical doctor / MD) who provide anesthesia to individuals with a phobia, fear, and anxiety for outpatient procedures in fields such as dermatology, plastic surgery, gastroenterology (upper gastrointestinal endoscopy, esophagogastroduodenoscopy, EGD, colonoscopy, otolaryngology (ear, nose, throat / ENT), and dentistry (deep cleaning, implant, all-on-four, root canal, and wisdom teeth extraction).

We provide various levels of anesthesia–from monitored anesthesia care (MAC) to general anesthesia. MAC is often used interchangeably with conscious sedation and twilight anesthesia. As it relates to dentistry, it is referred to as sleep dentistry, sedation dentistry, dental anesthesia, and intravenous, or IV, sedation.

We practice in Northern (Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, and Sonoma counties) and Southern (Los Angeles, Orange, San Bernardino, Riverside, Ventura, and San Diego counties) California.

Am I awake?

From time to time, patients ask if they may experience awareness as depicted in the movie Awake, which was released almost seven years ago. In it, the protagonist, patient Clay Beresford (Hayden Christensen), is partially paralyzed by a medication but is not asleep and feels surgical pain and manipulation. He dreams of his new wife Sam Lockwood (Jessica Alba) to distract himself from the pain and then comes to realize she poisoned his donor heart to kill him and collect on his life insurance. The movie is fanciful and takes liberal creative license to describe the work of anesthesiologists and surgeons. Fortunately, the events and many facts, including the anesthetic techniques, are works of fiction.

Awareness is thought to occur 0.0069 to 0.1% of the time, with the higher number reported by the movie. To be sure, awareness is more common with cardiac surgery and the use of muscle relaxants (neuromuscular blocking agents). When these medications are not used, patient movement during surgery can be a sign that the patient is not deeply asleep–but still not aware–and the attentive anesthesiologist can give additional medication to keep the patient comfortable. For less involved procedures performed in the office, muscle relaxants are not required and can make awareness less likely to occur.

Another problem is that anesthesia and surgical teams are made to look unprepared. In fact, teams are typically prepared well in advance and communication is of critical importance. The preoperative evaluation is usually performed by the anesthesiologist prior to entering the operating room to, among other things, ensure that chronic conditions are optimally controlled prior to surgery, tailor an anesthesia plan, explain risks, obtain informed consent, and answer questions. The anesthesiologist also performs airway management, maintains life support, administers pain control, and manages the post-operative course.

The anesthesiologist is Dr. Larry Lupin (Christopher McDonald) and is shown drinking from a flask during a break. Substance use among physicians is wholly unacceptable just as it is in most professions. Within the profession, there is a responsibility to confront physicians who are impaired, and the consequences they face are severe, including loss of privileges to administer anesthesia, disciplinary actions by a medical board, criminal charges, and reporting to the National Practitioner Data Bank (NPDB).

Even in the absence of substance abuse, anesthesiologists are taught early on in their careers to adhere to the American Society of Anesthesiologists’ motto, which is “vigilance”. In order to address the needs of the patient while he or she is asleep, the anesthesiologist must also be continuously present, which means not leaving the room without another person assuming care of the patient. An exception that was not clearly noted in the film is cardiac surgery when a perfusionist has the patient on cardiopulmonary bypass, where the patient is being maintained on a pump. In such a case, the anesthesiologist may leave the room, but the patient was not on bypass when Dr. Lupin left the room. A perfusionist and this medical device are not used in outpatient surgery.

Anesthesiologists are also responsible for administering cardiopulmonary resuscitation (CPR) during an emergency, such as the one that occurred near the end of the film when Mr. Beresford’s mother (Lena Olin) overdoses on medication. Techniques that could be performed in such an instance includes supplementation of oxygen, insertion of an endotracheal, or breathing, tube, compression of the chest, and administration of life-saving medications.

My answer to my patients’ question of encountering awareness is very unlikely. There are other things that can be said about this movie but commenting on them falls outside our scope of practice.

References

1. Barash P, Cullen B, Stoelting R, et al., eds. Clinical Anesthesia. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins.

2. Hughes PH, Brandenburg N, Baldwin DC, Jr., et al: Prevalence of substance use among US physicians. JAMA 1992; 267: 2333.

3. Miller RD, Eriksson LI, Fleisher L, et al., eds. Miller’s Anesthesia. 7th ed. Philadelphia, PA: Churchill Livingstone.

4. Ontario’s Anesthesiologists (2007-11-30). “Ontario’s Anesthesiologists Criticize the Film Awake”. CNW Group. Retrieved 2014-10-06.

5. Sandin RH, Enlund G, Samuelsson P, et al: Awareness during anaesthesia: A prospective case study. Lancet 2000; 355: 707.

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We are physician anesthesiologists (medical doctor / MD) who provide anesthesia to individuals with a phobia, fear, and anxiety for outpatient procedures in fields such as dermatology, plastic surgery, gastroenterology (upper gastrointestinal endoscopy, esophagogastroduodenoscopy, EGD, colonoscopy, otolaryngology (ear, nose, throat / ENT), and dentistry (deep cleaning, implant, all-on-four, root canal, and wisdom teeth extraction).

We provide various levels of anesthesia–from monitored anesthesia care (MAC) to general anesthesia. MAC is often used interchangeably with conscious sedation and twilight anesthesia. As it relates to dentistry, it is referred to as sleep dentistry, sedation dentistry, dental anesthesia, and intravenous, or IV, sedation.

We practice in Northern (Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, Solano, and Sonoma counties) and Southern (Los Angeles, Orange, San Bernardino, Riverside, Ventura, and San Diego counties) California.