So in the last entry, I got into what exactly happens in the time between leaving the preoperative area holding room and the time you go to sleep, with the monitors and oxygen being applied, but usually not remembered by the patient due to the amnesia properties of midazolam...
It is at this point that general anesthesia begins. I get asked all the time, not unreasonably, about what kinds of drugs I will use. Being that most patients don't know or care much about pharmacology, I don't bore the crap out of them with details. Most want to know if I will give them "gas." Most are surprised by my reply, which is that the actual drug that initially puts them to sleep is given through the IV. That drug, which is used in 98 to 99 percent of anesthetics in the United States, is propofol, which has unfortunately gained quite a notorious reputation due to its link to the death of Michael Jackson.
Propofol, in the right hands, i.e. those of a trained and skilled anesthesiologist or nurse anesthetist, is a very safe drug. It has been used millions of times in operating rooms in the last twenty years and has a great track record of success. But it does two important things. It makes the blood pressure go down significantly, and when given in the quantities needed to induce general anesthesia, it slows and even stops breathing. Now these are the qualities that can make it dangerous when not given in the proper setting. That's why the monitors are put on the patient before they go to sleep, so that if the blood pressure goes down and/or the breathing stops, we can do something about it right away.
Fortunately, when I give propofol to a patient to put them to sleep for anesthesia, I'm not walking out of the room or standing in another room while other people give it. I, like every other anesthesiologist who does the same thing, am right there, standing at the head of the patient's bed, waiting for them to fall asleep. Once they are asleep, I use the mask, which is attached to an anesthesia machine, to help them breathe.
Propofol also hurts when it's injected. We try to give a little bit of local anesthetic through the IV with the propofol, to try to diminish that discomfort. Usually it works; sometimes it doesn't. Fortunately, because of the midazolam the patient has received before, they don't remember the displeasure of that experience.
Once the propofol has been given to put the patient initially to sleep, then that is the point where we turn on the anesthetic gas, and that keeps the patient asleep during the duration of the surgery. The problem is that we need a way to give that gas, and if the initial medicine has made the patient stop breathing, then we need to breathe for them. So some sort of tube is inserted into the patient's mouth and is hooked up to a breathing machine from there.
Often, especially in shorter surgeries, the tube that is placed in the patient's mouth is a soft, plastic or rubber tube called a laryngeal mask airway, or LMA. The LMA has a large, teardrop shaped cuff at one end, which when placed correctly, sits on top of the opening to the esophagus and vocal cords. It's usually fairly straightforward to put in; the patient's mouth is opened and the LMA is just gently inserted. It's the other kind of tube that is put in, an endotracheal tube, that is what most people associate when they think of a "breathing tube."
An intubation, as it is called, is the process of placing one of these endotracheal tubes into the patient's mouth and through their vocal cords, where the tip of the tube sits inside the trachea. From this point, the other end of the tube can be attached to an anesthesia machine, and the anesthetic gases that keep the patient asleep can be given.
An intubation, to a layperson who has never seen one before, is kind of a wild procedure. It always amazes me when I'm intubating a patient and can see out of the corner of my eye, some medical student or nursing student and the shocked look on their face. They're fascinated and horrified at the same time.
I remember the first time I saw an intubation as a medical student. The anesthesiologist tilted the patient's head back a little bit, opened the mouth, and stuck this...big, metal thing...into the patient's mouth, and then after some maneuvering, grabbed the breathing tube and shoved it into the patient's mouth for what seemed like forever. I thought he would shove it in so far that it'd get lost. And as he pushed the tube in, I could see the patient's Adam's apple sort of bounce up. I swallowed hard, and I think I felt a little twinge of sympathy pain in my own throat at that point.
I found later on that the big metal thing was a laryngoscope, a metal flashlight of sorts with a straight, dull metal blade attached to it. When held in the right position, a little light shines down the length of the blade. The blade is placed into the patient's mouth to move the tongue out of the way and visualize the epiglottis and vocal cords. Once the vocal cords are in view, it is just a matter of guiding, gently, the tube through them. It's not nearly as violent a procedure as I witnessed that day, but it can be a challenging one that takes some getting used to. But again, as general anesthesia slows or even stops the patient's breathing, it is up to the anesthesiologist to maintain an airway and use that airway to breathe for the patient during the duration of the surgery. That's where the intubation comes in. There is method to the madness...
Thursday, December 1, 2011
Wheeling on back
So you're having surgery...you get to the operating room area, where the nurses greet you, ask you to take off all of your clothes and put on this skimpy little gown, and ask you a bunch of questions. Then a couple more people ask you all of the same questions, and you're thinking, Didn't any of you guys read my chart? And that's where your anesthesiologist comes in, promising you amnesia and the absence of pain, hopefully reassuring you that all will be OK.
The role of the anesthesiologist before the operation starts is one of reassurance. Once they have checked over your medical records and history and determine that it is indeed safe for you to receive anesthesia, they want to ease whatever (understandable) anxiety you might have about the surgery. Of course, a large part of that is done through verbal reassurance, but, yes, drugs do play a major part in the process.
Somewhere between the holding area where you get dressed for surgery and the actual operating room, the anesthesiologist slips you a little medication through your IV. There are a few ones that can be used, but these days, by far the most common drug used for this purpose is midazolam, also known by the trade name of Versed. For those who want to know, it is a class of drug known as a benzodiazepine, which potentiates an inhibitory neurotransmitter in the nervous system known as GABA. The great thing about midazolam in the context of preparing patients for surgery is that it causes amnesia. It probably doesn't take longer than 30 seconds to work, and it only lasts about 30 minutes, but in that time, it's enough for people to forget completely about the entire process of leaving the surgery holding area and going into the operating room.
So most of the time, by the time the patient gets to the operating room, they have had midazolam, and though they may look and act normally to the casual observer, they in fact will have amnesia of the events in question. Patients move themselves onto the operating table and make small talk with the OR staff and the anesthesiologist, and usually don't remember a second of it. Midazolam can make some people a little bit disinhibited as well, so occasionally we'll get the patient who suddenly gets into confessional mode when the drugs are on board. I actually know people who worked in the OR with me who, when they needed elective surgery, decided to have it done somewhere else because they were so afraid of what they might say when they were given midazolam.
The good thing, though, is that midazolam calms the anxious patient and that is good for everyone. Once the patient is in the room, they are monitored with several things, just like in the holding area - a blood pressure cuff, EKG pads for the heart, and a small probe on the finger. This is a pulse oximeter, which measures a value known as the oxygen saturation, a measure of how much oxygen is in the blood. It also makes a distinctive high-pitched beeping sound in concert with the patient's heartbeat and is a useful tool in that regard.
Usually, while the anesthesiologist is placing these monitors, the OR nurses, and whoever else may be in the room (surgeons, medical students, etc.) are doing other stuff to the patient. One particularly important thing is the placement of these funny compression devices around the legs - they make the legs look like they're wrapped in large white inflatable tortillas. They inflate and deflate periodically during the surgery, squeezing the legs in the process. This device is called an SCD, or Sequential Compression Device. It is important because the leg squeezing that it does promotes the continuous flow of blood in the legs.
During anesthesia, and especially during the beginning of anesthesia, the blood in the patient's legs tends to slow down as sleep sets in and the blood pressure goes down. The problem with slowed blood is that it increases the risk of forming a blood clot in the leg, which can then travel up to the lung. When this happens, it is called a pulmonary embolism, and it can be fatal. These squeezing devices, funny though they look, are very effective and have greatly decreased the incidence of what used to be a rare but all-too-common complication of even routine general anesthetics.
But I digress. Once all of these monitors and sequential devices are placed, the patient is then ready to go off to sleep. But it's not as simple as slapping a gas mask on them or slamming drugs through the IV. First, the patient is given oxygen to breathe through a mask. Often, when people are not sedated until they actually come into the room, this is the last thing they remember, lying on the bed, looking up at the ceiling, with a mask on top of their nose and mouth.
As a medical student, I never understood, watching the anesthesiologists put patients to sleep, why in the world they did this. Why didn't they just go right to the gas? What's the point? Well, the normal air we breathe is about 21% oxygen; most of the rest of it is nitrogen. Right before going to sleep, when the patient breathes 100% oxygen, it fills their lungs with oxygen and removes the nitrogen. Nitrogen is nice, but it doesn't help human cells metabolize and thrive like oxygen does. All that oxygen serves as a safety net of sorts; if for some reason the breathing slows or stops as the patient goes to sleep, there is enough oxygen in the blood that a few seconds of not breathing won't be a disaster. So the oxygen mask is a nice thing to do for patients, allowing them to relax with the deep breaths we ask them to take, but it serves this safety purpose as well.
So at this point, with the monitors on and the oxygen in place being breathed by the patient, the induction of anesthesia - the "going to sleep" part - can begin...
The role of the anesthesiologist before the operation starts is one of reassurance. Once they have checked over your medical records and history and determine that it is indeed safe for you to receive anesthesia, they want to ease whatever (understandable) anxiety you might have about the surgery. Of course, a large part of that is done through verbal reassurance, but, yes, drugs do play a major part in the process.
Somewhere between the holding area where you get dressed for surgery and the actual operating room, the anesthesiologist slips you a little medication through your IV. There are a few ones that can be used, but these days, by far the most common drug used for this purpose is midazolam, also known by the trade name of Versed. For those who want to know, it is a class of drug known as a benzodiazepine, which potentiates an inhibitory neurotransmitter in the nervous system known as GABA. The great thing about midazolam in the context of preparing patients for surgery is that it causes amnesia. It probably doesn't take longer than 30 seconds to work, and it only lasts about 30 minutes, but in that time, it's enough for people to forget completely about the entire process of leaving the surgery holding area and going into the operating room.
So most of the time, by the time the patient gets to the operating room, they have had midazolam, and though they may look and act normally to the casual observer, they in fact will have amnesia of the events in question. Patients move themselves onto the operating table and make small talk with the OR staff and the anesthesiologist, and usually don't remember a second of it. Midazolam can make some people a little bit disinhibited as well, so occasionally we'll get the patient who suddenly gets into confessional mode when the drugs are on board. I actually know people who worked in the OR with me who, when they needed elective surgery, decided to have it done somewhere else because they were so afraid of what they might say when they were given midazolam.
The good thing, though, is that midazolam calms the anxious patient and that is good for everyone. Once the patient is in the room, they are monitored with several things, just like in the holding area - a blood pressure cuff, EKG pads for the heart, and a small probe on the finger. This is a pulse oximeter, which measures a value known as the oxygen saturation, a measure of how much oxygen is in the blood. It also makes a distinctive high-pitched beeping sound in concert with the patient's heartbeat and is a useful tool in that regard.
Usually, while the anesthesiologist is placing these monitors, the OR nurses, and whoever else may be in the room (surgeons, medical students, etc.) are doing other stuff to the patient. One particularly important thing is the placement of these funny compression devices around the legs - they make the legs look like they're wrapped in large white inflatable tortillas. They inflate and deflate periodically during the surgery, squeezing the legs in the process. This device is called an SCD, or Sequential Compression Device. It is important because the leg squeezing that it does promotes the continuous flow of blood in the legs.
During anesthesia, and especially during the beginning of anesthesia, the blood in the patient's legs tends to slow down as sleep sets in and the blood pressure goes down. The problem with slowed blood is that it increases the risk of forming a blood clot in the leg, which can then travel up to the lung. When this happens, it is called a pulmonary embolism, and it can be fatal. These squeezing devices, funny though they look, are very effective and have greatly decreased the incidence of what used to be a rare but all-too-common complication of even routine general anesthetics.
But I digress. Once all of these monitors and sequential devices are placed, the patient is then ready to go off to sleep. But it's not as simple as slapping a gas mask on them or slamming drugs through the IV. First, the patient is given oxygen to breathe through a mask. Often, when people are not sedated until they actually come into the room, this is the last thing they remember, lying on the bed, looking up at the ceiling, with a mask on top of their nose and mouth.
As a medical student, I never understood, watching the anesthesiologists put patients to sleep, why in the world they did this. Why didn't they just go right to the gas? What's the point? Well, the normal air we breathe is about 21% oxygen; most of the rest of it is nitrogen. Right before going to sleep, when the patient breathes 100% oxygen, it fills their lungs with oxygen and removes the nitrogen. Nitrogen is nice, but it doesn't help human cells metabolize and thrive like oxygen does. All that oxygen serves as a safety net of sorts; if for some reason the breathing slows or stops as the patient goes to sleep, there is enough oxygen in the blood that a few seconds of not breathing won't be a disaster. So the oxygen mask is a nice thing to do for patients, allowing them to relax with the deep breaths we ask them to take, but it serves this safety purpose as well.
So at this point, with the monitors on and the oxygen in place being breathed by the patient, the induction of anesthesia - the "going to sleep" part - can begin...
Monday, October 31, 2011
What just happened?
I had my wisdom teeth taken out in an oral surgeon's office when I was 19 and that is the only time I have ever had general anesthesia. Here's what I remember. First, I lay down and the nurses put monitors on me. I started hearing beeping noises and was reassured that that was merely my own heartbeat. Then they started an IV, put a mask over my nose, and...
Then I was lying sideways on a cart in the recovery room, groggy, with my sister imploring me to get up so that she could drive me home. Apparently surgery was done, which was very confusing to me, because I had last remembered the monitors and the mask, with a few people milling around me. Later that evening, she also informed me that I had been given a whole litany of postoperative instructions during that time in the recovery room, none of which I remembered. Strangely, at least to me, the nurse gave those instructions knowing I wouldn't remember them, but told them to me anyway. Thank goodness for my sister.
With maybe a few changes in syntax, that is what the vast majority of people experience when they get a general anesthetic. It is a wonderful thing that we are able to do by managing the various drugs at our disposal. A surgical operation, be it 10 minutes or 10 hours, always feels to the patient as though it took 10 seconds. But what happens in between? That is what a log of this blog is intending to look at, and in the next few entries, I just want to go through, step by step, just exactly what is happening from the anesthesiologist's perspective while you are asleep in surgery.
Then I was lying sideways on a cart in the recovery room, groggy, with my sister imploring me to get up so that she could drive me home. Apparently surgery was done, which was very confusing to me, because I had last remembered the monitors and the mask, with a few people milling around me. Later that evening, she also informed me that I had been given a whole litany of postoperative instructions during that time in the recovery room, none of which I remembered. Strangely, at least to me, the nurse gave those instructions knowing I wouldn't remember them, but told them to me anyway. Thank goodness for my sister.
With maybe a few changes in syntax, that is what the vast majority of people experience when they get a general anesthetic. It is a wonderful thing that we are able to do by managing the various drugs at our disposal. A surgical operation, be it 10 minutes or 10 hours, always feels to the patient as though it took 10 seconds. But what happens in between? That is what a log of this blog is intending to look at, and in the next few entries, I just want to go through, step by step, just exactly what is happening from the anesthesiologist's perspective while you are asleep in surgery.
Sunday, September 18, 2011
Awareness in surgery: a view from an anesthesiologist
During general anesthesia, a surgical patient needs to be given a combination of drugs that ensures four basic things: 1) immobility 2) muscle relaxation 3) hypnosis, and 4) amnesia. The first two are the chief concerns of the surgeon, but the most pressing one for the patient is the last one. I get asked by patients about it almost every day. "I'm not gonna remember, am I?" My answer is always the same - not if I can help it.
I have been an anesthesiologist for a decade now, and I have yet to have an incident of intraoperative awareness that I know of. However, it is a well documented phenomenon, and one that is a big problem for people who have experienced it. I have interviewed a few patients who remembered being awake during surgery, and though a few were nonchalant about it, most were absolutely horrified by the experience, and for good reason. Imagine it - you're having surgery, you can't move, and you are (supposedly) unconscious. Yet you remember incidents during your operation, including being cut open, or people talking about you. Worse yet, you feel pain but can't do anything about it. Just thinking about it is nauseating, and I wouldn't wish it on my worst enemy.
There are a few things I want to discuss regarding this phenomenon. First, how often does it happen? Second, when does it happen? Third, how (in the world?!?!) could any anesthesiologist let it happen?
Incidence:
There have been numerous studies documenting how often recall under general anesthesia occurs, and they vary. Some cite an incidence of up to 0.9% - almost 1 in a hundred. That's a lot. There was a more recent study from the University of Illinois at Chicago that looked at almost 180,000 patients over a three year period that had undergone general anesthesia. They found an incidence of recall of about 0.006%, or 1 in about 14,500. That's not a lot - but try telling that to the one person out of that 14,500 who was awake during surgery. I'm more inclined to believe the more recent study, as anesthetic techniques have changed over the years and we have a wide range of drugs at our disposal to ensure amnesia.
When (and how) it happens:
Type of surgery
Not all general anesthetics are the same from the standpoint of recall. There are some cases where the risk of being aware during anesthesia is significantly higher than in others:
1. Cardiac surgery - A lot of the first documented widespread episodes of intraoperative awareness were during open heart surgery. I don't remember the statistics, but it's more than the 0.9% cited in previous studies on all general anesthetics.
2. C-sections under general anesthesia. General anesthesia presents a unique dilemma during a c-section. Of course, the woman in such a situation needs to be asleep to get her baby out. The problem is afterwards; the gases used in general anesthesia tend to relax the uterus. This may be a good thing when the obstetricians are trying to remove the baby, but afterwards, those relaxing properties prevent the uterus from contracting, and this can increase the risk of bleeding. So the anesthesiologist is limited in how much anesthetic gas they can use.
3. Trauma surgery - The problem here is the condition trauma patients are in when they arrive to the OR. They are unstable, with low blood pressures. Most of the anesthetic drugs we give tend to lower the blood pressure, so if a patient comes in with a blood pressure of 60 over 40, for example, the last thing we should do is make it even lower with anesthetic drugs.
4. Emergency surgery, of any kind. The same logic applies here as in trauma surgery. A person having emergent surgery is unstable and tolerates even a small amount of anesthesia very poorly.
Type of patient
Not everyone is at the same risk for remembering stuff during anesthesia. If you fit into one of these categories, be aware that your risk is greater:
1. Users of alcohol and drugs. This makes total sense, doesn't it? If someone drinks a lot of alcohol or uses drugs of any kind, they have a greater tolerance to anesthesia. This doesn't just apply to street drugs like heroin or cocaine. It applies to prescription pain meds (like Vicodin or Oxycontin) and prescription sedatives/anti-anxiety drugs (like Valium or Xanax). People who use these drugs are just a little different from the rest of us. For one, their livers are turbocharged and spit out anesthetic drugs quickly. For another, their brain cells have fewer receptors for anesthesia drugs, so it takes more drug to affect those brain cells.
2. People on antidepressants. See above. These drugs tend to make the liver metabolize drugs faster.
3. People who have had similar episodes before. Another intuitive one. If, for some reason a patient was aware during anesthesia even though everything sounded OK medically, there's probably something going on with that patient. We don't know exactly how these anesthetic gases work; as such, it's hard to predict how or why some people just aren't as affected by them as others.
4. People who have been told that they might be aware during anesthesia. No one is sure why that is; I suppose you could look at it as a self-fulfilling prophecy kind of thing.
5. Redheads. What?!?!? Seriously? It has always been a unwritten rule, especially among the older anesthesiologists, that redheads need more anesthesia for reasons no one knows. I always dismissed these old geezers as a bunch of idiots, but a study came out in one of our major journals in the last few years, and it backed it up. Granted, the study was very small, but it did show that redheads needed significantly more inhaled anesthetic gas (up to 20% more!) to maintain the same level of anesthesia as non-redheads. Believe what you may, I guess. I'm just putting it out there...
I have been an anesthesiologist for a decade now, and I have yet to have an incident of intraoperative awareness that I know of. However, it is a well documented phenomenon, and one that is a big problem for people who have experienced it. I have interviewed a few patients who remembered being awake during surgery, and though a few were nonchalant about it, most were absolutely horrified by the experience, and for good reason. Imagine it - you're having surgery, you can't move, and you are (supposedly) unconscious. Yet you remember incidents during your operation, including being cut open, or people talking about you. Worse yet, you feel pain but can't do anything about it. Just thinking about it is nauseating, and I wouldn't wish it on my worst enemy.
There are a few things I want to discuss regarding this phenomenon. First, how often does it happen? Second, when does it happen? Third, how (in the world?!?!) could any anesthesiologist let it happen?
Incidence:
There have been numerous studies documenting how often recall under general anesthesia occurs, and they vary. Some cite an incidence of up to 0.9% - almost 1 in a hundred. That's a lot. There was a more recent study from the University of Illinois at Chicago that looked at almost 180,000 patients over a three year period that had undergone general anesthesia. They found an incidence of recall of about 0.006%, or 1 in about 14,500. That's not a lot - but try telling that to the one person out of that 14,500 who was awake during surgery. I'm more inclined to believe the more recent study, as anesthetic techniques have changed over the years and we have a wide range of drugs at our disposal to ensure amnesia.
When (and how) it happens:
Type of surgery
Not all general anesthetics are the same from the standpoint of recall. There are some cases where the risk of being aware during anesthesia is significantly higher than in others:
1. Cardiac surgery - A lot of the first documented widespread episodes of intraoperative awareness were during open heart surgery. I don't remember the statistics, but it's more than the 0.9% cited in previous studies on all general anesthetics.
2. C-sections under general anesthesia. General anesthesia presents a unique dilemma during a c-section. Of course, the woman in such a situation needs to be asleep to get her baby out. The problem is afterwards; the gases used in general anesthesia tend to relax the uterus. This may be a good thing when the obstetricians are trying to remove the baby, but afterwards, those relaxing properties prevent the uterus from contracting, and this can increase the risk of bleeding. So the anesthesiologist is limited in how much anesthetic gas they can use.
3. Trauma surgery - The problem here is the condition trauma patients are in when they arrive to the OR. They are unstable, with low blood pressures. Most of the anesthetic drugs we give tend to lower the blood pressure, so if a patient comes in with a blood pressure of 60 over 40, for example, the last thing we should do is make it even lower with anesthetic drugs.
4. Emergency surgery, of any kind. The same logic applies here as in trauma surgery. A person having emergent surgery is unstable and tolerates even a small amount of anesthesia very poorly.
Type of patient
Not everyone is at the same risk for remembering stuff during anesthesia. If you fit into one of these categories, be aware that your risk is greater:
1. Users of alcohol and drugs. This makes total sense, doesn't it? If someone drinks a lot of alcohol or uses drugs of any kind, they have a greater tolerance to anesthesia. This doesn't just apply to street drugs like heroin or cocaine. It applies to prescription pain meds (like Vicodin or Oxycontin) and prescription sedatives/anti-anxiety drugs (like Valium or Xanax). People who use these drugs are just a little different from the rest of us. For one, their livers are turbocharged and spit out anesthetic drugs quickly. For another, their brain cells have fewer receptors for anesthesia drugs, so it takes more drug to affect those brain cells.
2. People on antidepressants. See above. These drugs tend to make the liver metabolize drugs faster.
3. People who have had similar episodes before. Another intuitive one. If, for some reason a patient was aware during anesthesia even though everything sounded OK medically, there's probably something going on with that patient. We don't know exactly how these anesthetic gases work; as such, it's hard to predict how or why some people just aren't as affected by them as others.
4. People who have been told that they might be aware during anesthesia. No one is sure why that is; I suppose you could look at it as a self-fulfilling prophecy kind of thing.
5. Redheads. What?!?!? Seriously? It has always been a unwritten rule, especially among the older anesthesiologists, that redheads need more anesthesia for reasons no one knows. I always dismissed these old geezers as a bunch of idiots, but a study came out in one of our major journals in the last few years, and it backed it up. Granted, the study was very small, but it did show that redheads needed significantly more inhaled anesthetic gas (up to 20% more!) to maintain the same level of anesthesia as non-redheads. Believe what you may, I guess. I'm just putting it out there...
Saturday, September 17, 2011
The White Stuff: An informal look at propofol
In 2009 Michael Jackson passed away under tragic and unfortunate circumstances. The reason? It was an overdose of the anesthetic drug propofol. For over 20 years, propofol has been one of the most commonly used anesthetic drugs on earth, and if you had surgery during that time, it was more than likely used to put you to sleep. But until that June day two years ago, nobody outside of medicine had ever heard of it, and pundits were all over the TV in the days following Michael Jackson's death, speculating on how it might have killed him. That is a story for another blog entry. What I do want to do, however, is give a little insight into this mysterious drug, which even now I am asked about at least once a week. It is important because like I said, it is the single most common induction drug used today in anesthesia, and a little information goes a long way in reassuring anyone about to undergo anesthesia.
First of all, what is propofol? It is different from all of the other sedative drugs used in anesthesia today. It is not a benzodiazepine, like the more familiar drugs Valium or Klonopin. Nor is it a barbiturate, like sodium thiopental (Pentothal). Both of these drugs have known mechanisms of action; they make certain inhibitory substances in the nervous system more potent. Propofol is in its own unique class of drugs; it is what is known as a "hindered phenol".
No, I don't really know what that means either. Nor are people in general completely sure of how propofol works. It is thought that like other sedatives, it potentiates the action of certain inhibitory substances, or neurotransmitters, in the central nervous system.
Enough about that. Propofol is a relatively new drug, having just come along in the last twenty-five years or so. Unlike most other drugs, which are mixed in saline or water, propofol is mixed in a lipid emulsion, with a substance, lecithin, that is similar to egg whites. As such, propofol has a unique place in the pantheon of drugs because of its snow-white color. It is often offhandedly referred to by non-anesthesiologist medical personnel as "milk of amnesia," a moniker I find annoying, albeit understandable. Propofol does a few things that make it so valuable and useful for anesthesiologists:
It acts for a short time and is metabolized quickly. Propofol is given in a large dose in the beginning of an anesthetic to put patients to sleep, and it causes almost immediate unconsciousness. Within five to ten minutes, though, that large dose has completely worn off and the patient will awaken unless they are given more anesthetic.
It can cause that unconsciousness, yet can wear off quickly without lingering side effects.In fact, propofol, when used for sedation (or misused, like MIchael Jackson's physician did), needs to be given through a pump, continuously. Shortly after the propofol stops, the patient wakes up and has little if any of the "hangover" feeling that characterized many sedative drugs before it. That is a great, and very useful quality to have in a drug.
Propofol, however, has a couple of properties that can make it extremely dangerous if not used correctly. First, it can cause blood pressure to drop significantly, especially in someone who is dehydrated - like a patient having surgery, who has been instructed not to eat or drink for at least 8 hours before their procedure. If that drop in blood pressure isn't treated in some way and is allowed to continue for any period of time, it can cause significant damage to vital organs. Elderly people are especially susceptible to this.
But the most significant - and now, the most notorious - property of propofol is that it decreases breathing, and can cause it to stop completely if given in large enough doses. If that sounds alarming, it can be. Propofol is a very safe drug in the hands of anesthesia providers who are trained in how to manage the airway and breathe for the patient who cannot do so on their own. But for someone not trained in airway management, propofol can be an extremely dangerous drug indeed. Almost all medical personnel are trained in basic or advanced life support, which does involve learning how to maintain an airway in a patient who is not breathing, but very few are trained with advanced airway management skills that are critical to know when such drugs as propofol are being given.
Doctors from specialties outside anesthesiology, like GI doctors and cardiologists, use mild sedation for a lot of their procedures, and have recently petitioned for the privilege of using propofol. All have been turned down by the governing society of anesthesia, the American Society of Anesthesiologists. They are certainly capable doctors in their area of expertise; they just don't necessarily have the skills in resuscitation and airway management to help a patient who stops breathing from an accidental overdose of propofol. That's not their fault; their training focuses on their particular area of expertise. Anesthesiologists do resuscitation and airway management for a living.
Again, it bears repeating that of the millions of surgeries performed in the United States each year under general anesthesia, propofol is used to put patients to sleep in, oh, 99.9% of them. Propofol is used, safely, in almost all of those as well, because it is given by an anesthesia provider who is vigilantly watching the patient with the help of multiple monitors, and has been trained for years in its proper use.
First of all, what is propofol? It is different from all of the other sedative drugs used in anesthesia today. It is not a benzodiazepine, like the more familiar drugs Valium or Klonopin. Nor is it a barbiturate, like sodium thiopental (Pentothal). Both of these drugs have known mechanisms of action; they make certain inhibitory substances in the nervous system more potent. Propofol is in its own unique class of drugs; it is what is known as a "hindered phenol".
No, I don't really know what that means either. Nor are people in general completely sure of how propofol works. It is thought that like other sedatives, it potentiates the action of certain inhibitory substances, or neurotransmitters, in the central nervous system.
Enough about that. Propofol is a relatively new drug, having just come along in the last twenty-five years or so. Unlike most other drugs, which are mixed in saline or water, propofol is mixed in a lipid emulsion, with a substance, lecithin, that is similar to egg whites. As such, propofol has a unique place in the pantheon of drugs because of its snow-white color. It is often offhandedly referred to by non-anesthesiologist medical personnel as "milk of amnesia," a moniker I find annoying, albeit understandable. Propofol does a few things that make it so valuable and useful for anesthesiologists:
It acts for a short time and is metabolized quickly. Propofol is given in a large dose in the beginning of an anesthetic to put patients to sleep, and it causes almost immediate unconsciousness. Within five to ten minutes, though, that large dose has completely worn off and the patient will awaken unless they are given more anesthetic.
It can cause that unconsciousness, yet can wear off quickly without lingering side effects.In fact, propofol, when used for sedation (or misused, like MIchael Jackson's physician did), needs to be given through a pump, continuously. Shortly after the propofol stops, the patient wakes up and has little if any of the "hangover" feeling that characterized many sedative drugs before it. That is a great, and very useful quality to have in a drug.
Propofol, however, has a couple of properties that can make it extremely dangerous if not used correctly. First, it can cause blood pressure to drop significantly, especially in someone who is dehydrated - like a patient having surgery, who has been instructed not to eat or drink for at least 8 hours before their procedure. If that drop in blood pressure isn't treated in some way and is allowed to continue for any period of time, it can cause significant damage to vital organs. Elderly people are especially susceptible to this.
But the most significant - and now, the most notorious - property of propofol is that it decreases breathing, and can cause it to stop completely if given in large enough doses. If that sounds alarming, it can be. Propofol is a very safe drug in the hands of anesthesia providers who are trained in how to manage the airway and breathe for the patient who cannot do so on their own. But for someone not trained in airway management, propofol can be an extremely dangerous drug indeed. Almost all medical personnel are trained in basic or advanced life support, which does involve learning how to maintain an airway in a patient who is not breathing, but very few are trained with advanced airway management skills that are critical to know when such drugs as propofol are being given.
Doctors from specialties outside anesthesiology, like GI doctors and cardiologists, use mild sedation for a lot of their procedures, and have recently petitioned for the privilege of using propofol. All have been turned down by the governing society of anesthesia, the American Society of Anesthesiologists. They are certainly capable doctors in their area of expertise; they just don't necessarily have the skills in resuscitation and airway management to help a patient who stops breathing from an accidental overdose of propofol. That's not their fault; their training focuses on their particular area of expertise. Anesthesiologists do resuscitation and airway management for a living.
Again, it bears repeating that of the millions of surgeries performed in the United States each year under general anesthesia, propofol is used to put patients to sleep in, oh, 99.9% of them. Propofol is used, safely, in almost all of those as well, because it is given by an anesthesia provider who is vigilantly watching the patient with the help of multiple monitors, and has been trained for years in its proper use.
Thursday, September 15, 2011
To-do list: the responsibilities of the anesthesiologist
This is the first part of unraveling the mystery of what exactly we anesthesiologists are doing while our patients are asleep. Everyone who has had general anesthesia knows the experience. You go into the room and you may vaguely recall seeing the inside of the OR, getting onto the OR table and lying down, and then...you're done. What happens in between? The answer to that question is more complex than meets the eye. Some of our tasks are obvious; some are less so. Either way, a lot of things that happen in an awake person without them even thinking about it don't happen at all under anesthesia. That is where the anesthesiologist takes over. Literally.
ABC. This is the most obvious and yet far-reaching task of the anesthesiologist, and it stands for Airway-Breathing-Circulation. In an awake person, the airway is maintained by muscle tone in the mouth and throat, muscle tone which decreases dramatically under anesthesia. Airway refers to giving the patient a means by which to exchange oxygen with the outside world. That can be a lot of things; usually it is a breathing tube placed in the mouth and windpipe, called, unsurprisingly, an endotracheal tube. There are several other airway devices placed in the mouth that can also be used for this purpose, or even a mask hooked up to tubing and an anesthesia machine will do. Of the members of the anesthesiologist's mighty triumvirate of ABC, A (airway) is king. Without it, nothing else matters.
Breathing. Duh. Of course we need to breathe, right? Yes , and we do so just fine while awake; the problem is that general anesthesia, and most sedatives for that matter, decrease the body's desire to breathe, and some drugs stop breathing completely. In my first post on this blog, I mentioned that each general anesthetic literally involves giving enough drugs to kill a person. It put off a few people who read it, but I'll explain myself here. Any drug that slows down breathing can be extremely dangerous, because it requires vigilance to administer it. If you were to give someone drugs to slow or stop their breathing and then just walk away, you'd kill them. But that's not the case at all in anesthesia. A trained anesthesia professional is sitting right there, using a mask to help the patient breathe, or more commonly, hooking their breathing tube up to an anesthesia machine that breathes for them.
Circulation. Almost all of the drugs used in general anesthesia also decrease the blood pressure, some more than others, but the important thing is that the anesthesiologist maintains the blood pressure. It has to be high enough that vital organs like the brain, heart, kidneys, etc. get enough blood to function well, but low enough that the patient doesn't bleed too much or suffer a stroke. This all has to be done against the backdrop of some interloper (oh, those surgeons!) performing painful and intentional trauma on the body, which understandably causes a great deal of stress on the body and a strong adrenaline rush. That's why we give anesthesia in the first place. It is a balancing act often determined by many things, including the patient's health and the kind of surgery being performed. Ultimately, circulation, namely blood pressure, tells us how we're doing. Too much anesthesia and the patient's blood pressure is dangerously low. Too little, and it's high. And the patient moves. And...the patient remembers. Which leads me to my next point...
Make sure the patient doesn't remember. This seems obvious, right? But in older times, it was not unheard of to use the anesthetic technique of giving only a small amount of anesthesia combined with a muscle relaxant to keep the patient from moving. So the patients were immobile for the surgery, but if the anesthetist underestimated how much drug to give by even a little, well, that's where the nightmare stories on news shows came about, with patients hearing their surgeons talking during their operation or feeling pain but unable to tell anyone. Part of any general anesthetic is to ensure complete amnesia of everything that happens during the surgery.
Make sure the patient doesn't move. This is another painfully obvious job here, but it bears repeating. it is unreasonable to ask any surgeon to have to hit a moving target with their scalpels or sutures.
Protect the nerves. What do I mean here? When you're asleep, you're immobile, of course, during the duration of the surgery. Though it's necessary for the surgeons, it is not normal in real life, and that presents its own set of problems. When you you go to bed at night, you don't stay in the same position. You start on your back, switch to one side, maybe switch again to the other side, even go to your stomach. You have to, or you'll get numb from lying in the same position for hours. That's where the anesthesia problem lies. There are certain parts on the body where nerves are very superficial to the skin, and those parts are especially susceptible to being injured when placed in the same position for too long.
First among these is that spot on the inside of your elbow, the funny bone, known in medical terms as the ulnar groove. If that is pressed on too vigorously while the patient is lying still for their surgery, it can cause injury to the 4th and 5th fingers on that hand - numbness, tingling, and even permanent weakness. It's the anesthesiolgist's job to make sure that doesn't happen. Vulnerable spots like the funny bone are padded heavily while under anesthesia, to ensure too much pressure isn't placed on them. Other key places to protect and pad during anesthesia are the back of the forearm (radial nerve) and the outside of the knee (peroneal nerve).
Protect the eyes. An awake person has many ways to protect their eyes. Cover them with their hand, maybe, or even just close the eyes tightly. If a small speck gets in the eye, it reflexively starts making tears to wash the offending thing out. Under anesthesia, all such defenses are gone, so the anesthesiologist must again take over. They will often put a mild lubricant in the eye, some sort of artificial tears, to make sure the eye stays moist. Then, the eyes are taped closed, to make sure they don't accidentally open and expose the eyeball. Some people even put plastic shields over the taped eyes, like a pair of wraparound sunglasses, to make sure the eyes aren't harmed. The eyes, so valuable and vulnerable, are
watched VERY carefully during surgery.
These are some of the high points. There are more, but you get the idea. The bottom line is that the patient, while under anesthesia, is as defenseless as a little baby, and regardless of what kind of operation is being done, needs to be protected in even basic ways. That is the task of your anesthesiologist.
ABC. This is the most obvious and yet far-reaching task of the anesthesiologist, and it stands for Airway-Breathing-Circulation. In an awake person, the airway is maintained by muscle tone in the mouth and throat, muscle tone which decreases dramatically under anesthesia. Airway refers to giving the patient a means by which to exchange oxygen with the outside world. That can be a lot of things; usually it is a breathing tube placed in the mouth and windpipe, called, unsurprisingly, an endotracheal tube. There are several other airway devices placed in the mouth that can also be used for this purpose, or even a mask hooked up to tubing and an anesthesia machine will do. Of the members of the anesthesiologist's mighty triumvirate of ABC, A (airway) is king. Without it, nothing else matters.
Breathing. Duh. Of course we need to breathe, right? Yes , and we do so just fine while awake; the problem is that general anesthesia, and most sedatives for that matter, decrease the body's desire to breathe, and some drugs stop breathing completely. In my first post on this blog, I mentioned that each general anesthetic literally involves giving enough drugs to kill a person. It put off a few people who read it, but I'll explain myself here. Any drug that slows down breathing can be extremely dangerous, because it requires vigilance to administer it. If you were to give someone drugs to slow or stop their breathing and then just walk away, you'd kill them. But that's not the case at all in anesthesia. A trained anesthesia professional is sitting right there, using a mask to help the patient breathe, or more commonly, hooking their breathing tube up to an anesthesia machine that breathes for them.
Circulation. Almost all of the drugs used in general anesthesia also decrease the blood pressure, some more than others, but the important thing is that the anesthesiologist maintains the blood pressure. It has to be high enough that vital organs like the brain, heart, kidneys, etc. get enough blood to function well, but low enough that the patient doesn't bleed too much or suffer a stroke. This all has to be done against the backdrop of some interloper (oh, those surgeons!) performing painful and intentional trauma on the body, which understandably causes a great deal of stress on the body and a strong adrenaline rush. That's why we give anesthesia in the first place. It is a balancing act often determined by many things, including the patient's health and the kind of surgery being performed. Ultimately, circulation, namely blood pressure, tells us how we're doing. Too much anesthesia and the patient's blood pressure is dangerously low. Too little, and it's high. And the patient moves. And...the patient remembers. Which leads me to my next point...
Make sure the patient doesn't remember. This seems obvious, right? But in older times, it was not unheard of to use the anesthetic technique of giving only a small amount of anesthesia combined with a muscle relaxant to keep the patient from moving. So the patients were immobile for the surgery, but if the anesthetist underestimated how much drug to give by even a little, well, that's where the nightmare stories on news shows came about, with patients hearing their surgeons talking during their operation or feeling pain but unable to tell anyone. Part of any general anesthetic is to ensure complete amnesia of everything that happens during the surgery.
Make sure the patient doesn't move. This is another painfully obvious job here, but it bears repeating. it is unreasonable to ask any surgeon to have to hit a moving target with their scalpels or sutures.
Protect the nerves. What do I mean here? When you're asleep, you're immobile, of course, during the duration of the surgery. Though it's necessary for the surgeons, it is not normal in real life, and that presents its own set of problems. When you you go to bed at night, you don't stay in the same position. You start on your back, switch to one side, maybe switch again to the other side, even go to your stomach. You have to, or you'll get numb from lying in the same position for hours. That's where the anesthesia problem lies. There are certain parts on the body where nerves are very superficial to the skin, and those parts are especially susceptible to being injured when placed in the same position for too long.
First among these is that spot on the inside of your elbow, the funny bone, known in medical terms as the ulnar groove. If that is pressed on too vigorously while the patient is lying still for their surgery, it can cause injury to the 4th and 5th fingers on that hand - numbness, tingling, and even permanent weakness. It's the anesthesiolgist's job to make sure that doesn't happen. Vulnerable spots like the funny bone are padded heavily while under anesthesia, to ensure too much pressure isn't placed on them. Other key places to protect and pad during anesthesia are the back of the forearm (radial nerve) and the outside of the knee (peroneal nerve).
Protect the eyes. An awake person has many ways to protect their eyes. Cover them with their hand, maybe, or even just close the eyes tightly. If a small speck gets in the eye, it reflexively starts making tears to wash the offending thing out. Under anesthesia, all such defenses are gone, so the anesthesiologist must again take over. They will often put a mild lubricant in the eye, some sort of artificial tears, to make sure the eye stays moist. Then, the eyes are taped closed, to make sure they don't accidentally open and expose the eyeball. Some people even put plastic shields over the taped eyes, like a pair of wraparound sunglasses, to make sure the eyes aren't harmed. The eyes, so valuable and vulnerable, are
watched VERY carefully during surgery.
These are some of the high points. There are more, but you get the idea. The bottom line is that the patient, while under anesthesia, is as defenseless as a little baby, and regardless of what kind of operation is being done, needs to be protected in even basic ways. That is the task of your anesthesiologist.
Tuesday, September 6, 2011
To sleep or not to sleep, Part II
So, just as promised, I want to go over the pros and cons of conscious sedation, so that if given the choice, you as a patient can make an informed decision about whether not to go completely to sleep for your surgery. First, I just want to more clearly define what I mean by "conscious sedation."
Conscious sedation refers to a level of anesthesia that is more than being completely awake, but less than being completely asleep. It is often referred to as "twilight" anesthesia, and the technical term for it is Monitored Anesthesia Care, called MAC for short. When patients receive MAC anesthesia, their consciousness is depressed somewhat. They have amnesia and are sedated enough that they may respond to very strong noxious stimuli but not much if at all to weaker stimuli. As opposed to a general anesthetic where the patient's breathing is significantly slowed down and their blood pressure can also decrease quite a bit, conscious sedation depresses these functions only mildly, if at all.
With that in mind, let's go over the good and bad of having conscious sedation.
The Good:
1. You're more awake during the surgery. In most cases, the amount of sedation you receive for such a case is enough that you don't remember anything, but not so much that you're totally out of it. Patients will sometimes remember hearing voices and the beeping sounds of monitors, but will note that they didn't really care about them and weren't worried or concerned about hearing them.
2. You wake up faster afterwards. The most common sedative administered during conscious sedation is propofol. Yes, that's the same drug that was misused by Michael Jackson, but in the hands of trained anesthesia professionals, it is a very safe drug. One of its best qualities is that it only lasts a few minutes, so during sedation it is given continuously into the IV via a small pump. When the surgery is done, the pump is discontinued, and the patient wakes up within a few minutes. There is little or none of the groggy feeling that so often accompanies general anesthesia.
3. Less nausea and vomiting. The stuff that really causes nausea is the combination of narcotics and the inhaled anesthetic gases that are used to maintain general anesthesia. With conscious sedation, there is no inhaled gas and significantly less narcotic being given.
4. Receiving less drugs = fewer side effects . General anesthesia is strong stuff. Even a "routine" general anesthetic involves the administration of some pretty potent medicines, ones that can drastically lower all bodily functions, including blood pressure, heart rate, neurologic function, even immune function. A general anesthetic is much more stressful on the body than conscious sedation.
The Bad:
1. You're more awake during the surgery. Again, the likelihood of remembering much at all during conscious sedation is quite small, but it's much more likely to happen than in general anesthesia. If you're the kind of person who wants to be totally knocked out and doesn't want to know anything, well, conscious sedation is not an optimal choice for you.
2. You may end up getting general anesthesia anyway. Everyone deals with conscious sedation differently. Some people do great with just a little bit of IV sedative and some local anesthetic in their incision. Others get uncomfortable - real uncomfortable. It's uncommon but possible that if you get too uncomfortable during your sedation, the anesthesiologist may have to put you to sleep anyway, defeating the whole purpose of having sedation.
3. Sedative-induced confessions. Yeah, this is a rare sort of thing, but there are some people, when given a small amount of sedative, start confessing like a sentimental college kid on graduation night. People know their tendencies. I know OR personnel I work with who have chosen to have their surgeries at outside hospitals just because they feared what they might say once they had a little sedation.
4. It can actually be more dangerous. This is especially true if you have issues with snoring or sleep apnea. When you are under general anesthesia, you have a breathing tube in your mouth that the anesthesiologist uses to help with your breathing. With conscious sedation, you have small plastic prongs in your nose that give oxygen, but that's about it. When people get sleepy, it is easier for the tissues in their mouth and throat to collapse, blocking the flow of oxygen into the lungs and causing blood oxygen levels to decrease dangerously. The vigilant anesthesia provider, of course, can deal with this accordingly, but even small lapses in vigilance can cause big, big problems. This leads me to the next point...
5. The quality of your conscious sedation experience is very anesthesiologist dependent. If you have an anesthesiologist or nurse anesthetist who is experienced with conscious sedation, and is working with a surgeon who is well aware of the issues faced by the anesthesiologist, things usually go very smoothly. But the problem is with anesthesia providers, like residents, who fail to understand a lot of the complexities that come with giving conscious sedation. I remember being a resident and thinking these cases would be easy; if anything, they are harder than general anesthesics, just for the fact that the patient is partially awake. These conscious sedation cases require, in many ways, more vigilance than general anesthetics.
Ultimately, whether you get general anesthesia or conscious sedation for your surgery depends on several things, including the type of surgery, and the experience/comfort of both your anesthesiologist and surgeon. Most importantly, there needs to be a three-way dialogue, between patient, surgeon, and anesthesiologist in order to arrive at a consensus of the best way to proceed.
Conscious sedation refers to a level of anesthesia that is more than being completely awake, but less than being completely asleep. It is often referred to as "twilight" anesthesia, and the technical term for it is Monitored Anesthesia Care, called MAC for short. When patients receive MAC anesthesia, their consciousness is depressed somewhat. They have amnesia and are sedated enough that they may respond to very strong noxious stimuli but not much if at all to weaker stimuli. As opposed to a general anesthetic where the patient's breathing is significantly slowed down and their blood pressure can also decrease quite a bit, conscious sedation depresses these functions only mildly, if at all.
With that in mind, let's go over the good and bad of having conscious sedation.
The Good:
1. You're more awake during the surgery. In most cases, the amount of sedation you receive for such a case is enough that you don't remember anything, but not so much that you're totally out of it. Patients will sometimes remember hearing voices and the beeping sounds of monitors, but will note that they didn't really care about them and weren't worried or concerned about hearing them.
2. You wake up faster afterwards. The most common sedative administered during conscious sedation is propofol. Yes, that's the same drug that was misused by Michael Jackson, but in the hands of trained anesthesia professionals, it is a very safe drug. One of its best qualities is that it only lasts a few minutes, so during sedation it is given continuously into the IV via a small pump. When the surgery is done, the pump is discontinued, and the patient wakes up within a few minutes. There is little or none of the groggy feeling that so often accompanies general anesthesia.
3. Less nausea and vomiting. The stuff that really causes nausea is the combination of narcotics and the inhaled anesthetic gases that are used to maintain general anesthesia. With conscious sedation, there is no inhaled gas and significantly less narcotic being given.
4. Receiving less drugs = fewer side effects . General anesthesia is strong stuff. Even a "routine" general anesthetic involves the administration of some pretty potent medicines, ones that can drastically lower all bodily functions, including blood pressure, heart rate, neurologic function, even immune function. A general anesthetic is much more stressful on the body than conscious sedation.
The Bad:
1. You're more awake during the surgery. Again, the likelihood of remembering much at all during conscious sedation is quite small, but it's much more likely to happen than in general anesthesia. If you're the kind of person who wants to be totally knocked out and doesn't want to know anything, well, conscious sedation is not an optimal choice for you.
2. You may end up getting general anesthesia anyway. Everyone deals with conscious sedation differently. Some people do great with just a little bit of IV sedative and some local anesthetic in their incision. Others get uncomfortable - real uncomfortable. It's uncommon but possible that if you get too uncomfortable during your sedation, the anesthesiologist may have to put you to sleep anyway, defeating the whole purpose of having sedation.
3. Sedative-induced confessions. Yeah, this is a rare sort of thing, but there are some people, when given a small amount of sedative, start confessing like a sentimental college kid on graduation night. People know their tendencies. I know OR personnel I work with who have chosen to have their surgeries at outside hospitals just because they feared what they might say once they had a little sedation.
4. It can actually be more dangerous. This is especially true if you have issues with snoring or sleep apnea. When you are under general anesthesia, you have a breathing tube in your mouth that the anesthesiologist uses to help with your breathing. With conscious sedation, you have small plastic prongs in your nose that give oxygen, but that's about it. When people get sleepy, it is easier for the tissues in their mouth and throat to collapse, blocking the flow of oxygen into the lungs and causing blood oxygen levels to decrease dangerously. The vigilant anesthesia provider, of course, can deal with this accordingly, but even small lapses in vigilance can cause big, big problems. This leads me to the next point...
5. The quality of your conscious sedation experience is very anesthesiologist dependent. If you have an anesthesiologist or nurse anesthetist who is experienced with conscious sedation, and is working with a surgeon who is well aware of the issues faced by the anesthesiologist, things usually go very smoothly. But the problem is with anesthesia providers, like residents, who fail to understand a lot of the complexities that come with giving conscious sedation. I remember being a resident and thinking these cases would be easy; if anything, they are harder than general anesthesics, just for the fact that the patient is partially awake. These conscious sedation cases require, in many ways, more vigilance than general anesthetics.
Ultimately, whether you get general anesthesia or conscious sedation for your surgery depends on several things, including the type of surgery, and the experience/comfort of both your anesthesiologist and surgeon. Most importantly, there needs to be a three-way dialogue, between patient, surgeon, and anesthesiologist in order to arrive at a consensus of the best way to proceed.
Monday, September 5, 2011
To sleep or not to sleep?
Anesthesia is always presumed to be the state of being asleep while you are having surgery, and since the advent of modern general anesthesia in the 1840s, that is more or less how it has been. But now, with the advent of new anesthetic techniques, as well as the presence of new drugs, it is not always necessary to have then patients completely asleep in order to have their surgery.
For a lot of operations, it really isn't an option to be asleep or not, such as open heart surgery or a liver transplant. But amazingly, just about every operation you can think of has been done without general anesthesia. Brain surgery, gallbladder removal, total knee and hip replacement, breast implants, facelifts, hysteroscopy - all have been done with minimal sedation, to the satisfaction of everyone involved. Just for the sake of sorting out then debate of being under general anesthesia or not, I thought I'd go through the pros and cons of general anesthesia versus being awake in some form.
Pros of general anesthesia:
1. It's a lot easier and quicker from the patient perspective. This is obvious. You go in the OR, get some drugs to relax you, and then all of a sudden, you're in the recovery room and your surgery is done. There is a lot to be said for that. Along those lines,
2. The chances of you moving during the surgery are slim to none. It may not matter to you because you won't remember it anyway, but if you're fidgeting around during the surgery, it is difficult for your surgeon and in some cases can be dangerous.
3. No drug induced confessions. The medicines used to keep people sleepy during conscious sedation make some people very chatty. Sometimes during that state of mind, people will say things that maybe they shouldn't. If you're the type of person who is a talkative drunk, for example, opt for the general anesthesia route.
4. You are much less likely to remember anything. I guess you can never guarantee anything, but the chances of remembering anything while under general anesthesia are very small.
Cons of general anesthesia:
1. It's a little more dangerous. General anesthesia involves significantly depressing your level of consciousness. With that comes decreasing your blood pressure and your breathing. Any time you decrease these parameters, the chances of something bad happening go up a little bit. now the chances of something bad happening to a healthy person undergoing a "routine" general anesthetic are very small, but not impossible. Every general anesthetic involves some degree of risk.
2. In all likelihood you'll be in more pain afterwards. During the general anesthetic you get medications to keep you motionless and comfortable. When the surgery is done, those medicines are discontinued, and you wake up. The trouble is that the pain relief properties of those medicines stops too. When you get conscious sedation, the surgeon almost always has to give local anesthetic into the area where the surgery is taking place, and so you wake up a little more comfortable.
3. Nausea. Vomiting. The gases used to keep you asleep during a general anesthetic have, as one of their common side effects, the tendency to make people puke. On one hand, a lot of people, if they get sick, do so in the recovery room and don't remember it. But a lot more get sick hours afterward, or even in the next day or two after surgery. Besides making the patient feel miserable, vomiting, if it happens often and/or vigorously enough, can affect the success of the surgery, causing wounds to open up or bleed in the worst case scenario.
4. Grogginess. In theory, most young healthy people will metabolize the inhaled gases and IV narcotics from a general anesthetic within 6 hours after the anesthetic is finished, but everyone is different. Some people can feel out of it for a day after anesthesia, or even longer. A lot of people don't like that "drugged up" feeling.
5. Loss of control. What's good for one person stinks for another. Many people like the idea of being taken to a happy place for an hour or two while some surgeon does stuff to them and they don't even have to know that any of it even happened. Others can't stand the idea of not knowing what's going on, not being in total control of the situation. Know anyone like that? Are you someone like that? If the words "control freak" have ever been used to describe you, this aspect of general anesthesia will not appeal to you at all.
6. You receive more drugs. If you're having conscious sedation, you get either a nerve block from the anesthesiologist or local anesthetic from the surgeon, and then the anesthesiologist gives you a small amount of sedative through the IV, not enough to make you completely asleep, but enough to make you feel relaxed and comfortable. General anesthesia involves a lot. There's a sedative, narcotics, anesthetic gas, muscle relaxants, etc. More drugs = more side effects.
Next blog I'll go through conscious sedation - what exactly it means, and its pros and cons.
For a lot of operations, it really isn't an option to be asleep or not, such as open heart surgery or a liver transplant. But amazingly, just about every operation you can think of has been done without general anesthesia. Brain surgery, gallbladder removal, total knee and hip replacement, breast implants, facelifts, hysteroscopy - all have been done with minimal sedation, to the satisfaction of everyone involved. Just for the sake of sorting out then debate of being under general anesthesia or not, I thought I'd go through the pros and cons of general anesthesia versus being awake in some form.
Pros of general anesthesia:
1. It's a lot easier and quicker from the patient perspective. This is obvious. You go in the OR, get some drugs to relax you, and then all of a sudden, you're in the recovery room and your surgery is done. There is a lot to be said for that. Along those lines,
2. The chances of you moving during the surgery are slim to none. It may not matter to you because you won't remember it anyway, but if you're fidgeting around during the surgery, it is difficult for your surgeon and in some cases can be dangerous.
3. No drug induced confessions. The medicines used to keep people sleepy during conscious sedation make some people very chatty. Sometimes during that state of mind, people will say things that maybe they shouldn't. If you're the type of person who is a talkative drunk, for example, opt for the general anesthesia route.
4. You are much less likely to remember anything. I guess you can never guarantee anything, but the chances of remembering anything while under general anesthesia are very small.
Cons of general anesthesia:
1. It's a little more dangerous. General anesthesia involves significantly depressing your level of consciousness. With that comes decreasing your blood pressure and your breathing. Any time you decrease these parameters, the chances of something bad happening go up a little bit. now the chances of something bad happening to a healthy person undergoing a "routine" general anesthetic are very small, but not impossible. Every general anesthetic involves some degree of risk.
2. In all likelihood you'll be in more pain afterwards. During the general anesthetic you get medications to keep you motionless and comfortable. When the surgery is done, those medicines are discontinued, and you wake up. The trouble is that the pain relief properties of those medicines stops too. When you get conscious sedation, the surgeon almost always has to give local anesthetic into the area where the surgery is taking place, and so you wake up a little more comfortable.
3. Nausea. Vomiting. The gases used to keep you asleep during a general anesthetic have, as one of their common side effects, the tendency to make people puke. On one hand, a lot of people, if they get sick, do so in the recovery room and don't remember it. But a lot more get sick hours afterward, or even in the next day or two after surgery. Besides making the patient feel miserable, vomiting, if it happens often and/or vigorously enough, can affect the success of the surgery, causing wounds to open up or bleed in the worst case scenario.
4. Grogginess. In theory, most young healthy people will metabolize the inhaled gases and IV narcotics from a general anesthetic within 6 hours after the anesthetic is finished, but everyone is different. Some people can feel out of it for a day after anesthesia, or even longer. A lot of people don't like that "drugged up" feeling.
5. Loss of control. What's good for one person stinks for another. Many people like the idea of being taken to a happy place for an hour or two while some surgeon does stuff to them and they don't even have to know that any of it even happened. Others can't stand the idea of not knowing what's going on, not being in total control of the situation. Know anyone like that? Are you someone like that? If the words "control freak" have ever been used to describe you, this aspect of general anesthesia will not appeal to you at all.
6. You receive more drugs. If you're having conscious sedation, you get either a nerve block from the anesthesiologist or local anesthetic from the surgeon, and then the anesthesiologist gives you a small amount of sedative through the IV, not enough to make you completely asleep, but enough to make you feel relaxed and comfortable. General anesthesia involves a lot. There's a sedative, narcotics, anesthetic gas, muscle relaxants, etc. More drugs = more side effects.
Next blog I'll go through conscious sedation - what exactly it means, and its pros and cons.
Sunday, August 28, 2011
Holding room: your pre-surgical talk with your anesthesiologist
Anesthesia is a weird field relative to other medical specialties. We don't have a clinic where we get to talk to patients at length, going into great detail about their medical histories and forming a plan of action afterwards. We don't see patients in multiple follow up visits. Besides pathology, anesthesia is one of the few fields where the doctor talks very little with the patient. But the 10 to 20 minutes that we do talk to our patients, right before surgery, are among the most precious few minutes that any patient can spend with their doctor. This encounter, formally referred to as the preoperative evaluation, gives us the information we need to know in order to give you a safe and effective anesthetic.
Most of what we ask patients in the preoperative evaluation is pretty standard stuff. What are your medical problems? Related to that, what medicines do you take? Are you allergic to anything? In almost any doctor's office, in any specialty, you'd get these kinds of questions. There are a few more questions in our evaluation, some of which are asked by others, but most of which are unique to us, or at least focused on more closely by us.
I'll put these in a list.
1. When was the last time you ate something? This is perhaps the single most important question to answer correctly before getting anesthesia. The answer needs to be either "nothing since midnight" or "nothing in the last 6 hours". The question I always get from patients is "why?". The short answer is that anesthesia and a full stomach are a bad and potentially fatal combination. I'll explain in detail in a later blog.
2. Do you smoke? Doesn't every doctor ask that? And if you smoke, isn't it friggin'
annoying? For us anesthesiologists, it's a big deal, because if you are going to sleep, we may choose to place a breathing tube through your vocal cords and into your trachea to help you breathe, known as an intubation. If you smoke, it means that your upper airways and trachea are very reactive and sensitive to anything touching them, like a breathing tube. Everyone finds the breathing tube irritating, but smokers really hate it, and sometimes, their upper airways can constrict severely in response to it, a phenomenon known as bronchospasm. It is dangerous and can cause the flow of oxygen to the lungs to decrease significantly. There are lots of other anesthesia related issues with smoking. Smokers generally have worse lung function that nonsmokers, with lower baseline oxygen levels, and they are less responsive to oxygen in general. They produce significant amounts of mucus, which can clog the breathing tube and make it harder to give anesthetic gas and oxygen. If you smoke, there's nothing I can do about it, of course, but knowing it helps me prepare for what might happen and work around it.
3. Do you have any loose teeth? Can you open your mouth? These go along with the whole intubation theme. If you have teeth that are loose, it is theoretically possible that they could be damaged when the breathing tube is either placed or removed. It is rare but possible. And if you have caps, crowns, veneers, or other expensive work on your teeth, especially the front ones, we need to know that as well for the same reason. And as for opening your mouth, that tells us another very important piece of information. How wide you open your mouth, how big your tongue is, how long and wide your chin is - all of these tell us how easy or how difficult it will likely be to do your intubation.
4. Have you ever been told you snore? Kind of a personal question, huh? Not everyone asks it, but I do, and it tells me about how you'll act right after you fall asleep, before I've done the intubation. If you snore, it means you likely have a lot of extra soft tissue in your mouth which vibrates to cause the snoring, and which can collapse when under anesthesia, causing your airway to obstruct. This can get dangerous very quickly. The snoring question also leads to other issues, most notably obstructive sleep apnea, which also greatly increases the risk of going under anesthesia.
5. Has anyone in your family ever had a problem with anesthesia? Usually the answer we get is along the lines of how someone's mom or grandma threw up after anesthesia, but what we're looking for is a rare, usually hereditary, and potentially fatal reaction to anesthesia known as malignant hyperthermia (MH). People with MH develop extremely high and potentially fatal fever in response to very specific anesthetic agents. If caught in time, it can usually be treated, but it's scary. People with a personal or family history of MH can still receive anesthesia, but we need to know that history beforehand, because the OR and anesthesia machines have to be prepared in a very specific way to ensure safety. Don't worry if you don't know all the details about how your grandfather had some weird reaction to anesthesia 70
years ago. If we're the least bit suspicious, you'll get the safe (called a "non-triggering") anesthetic.
6. Do you drink? Use drugs? This is really important to answer truthfully, because lying can literally mean the difference between remembering surgery or not - or between life and death. If you drink alcohol heavily, the amount of anesthesia you require to stay asleep and have amnesia of the surgery is increased. Makes sense, huh? So tell us. As for drugs, they too increase your tolerance to anesthesia, especially heroin or other opioids. The real dangerous one, though, is cocaine. Cocaine sensitized and desensitizes your brain to certain drugs in dangerous ways. Most notably, cocaine in combination with certain blood pressure meeds used in anesthesia can cause extremely high, potentially fatally high, blood pressure increases. Or it can cause the blood pressure to sink to nothing, extremely resistant to all but the strongest drugs. If you use cocaine, we've gotta know that! I don't care or judge how you live your life; I just don't want you to die while receiving anesthesia.
7. How tall are you? How much do you weigh? No, we're not trying to be nosy. A lot of the drugs we give are dosed based on your weight, some on your "ideal" weight, but most on your actual weight. It just helps us be accurate with our drug dosing.
Most of what we ask patients in the preoperative evaluation is pretty standard stuff. What are your medical problems? Related to that, what medicines do you take? Are you allergic to anything? In almost any doctor's office, in any specialty, you'd get these kinds of questions. There are a few more questions in our evaluation, some of which are asked by others, but most of which are unique to us, or at least focused on more closely by us.
I'll put these in a list.
1. When was the last time you ate something? This is perhaps the single most important question to answer correctly before getting anesthesia. The answer needs to be either "nothing since midnight" or "nothing in the last 6 hours". The question I always get from patients is "why?". The short answer is that anesthesia and a full stomach are a bad and potentially fatal combination. I'll explain in detail in a later blog.
2. Do you smoke? Doesn't every doctor ask that? And if you smoke, isn't it friggin'
annoying? For us anesthesiologists, it's a big deal, because if you are going to sleep, we may choose to place a breathing tube through your vocal cords and into your trachea to help you breathe, known as an intubation. If you smoke, it means that your upper airways and trachea are very reactive and sensitive to anything touching them, like a breathing tube. Everyone finds the breathing tube irritating, but smokers really hate it, and sometimes, their upper airways can constrict severely in response to it, a phenomenon known as bronchospasm. It is dangerous and can cause the flow of oxygen to the lungs to decrease significantly. There are lots of other anesthesia related issues with smoking. Smokers generally have worse lung function that nonsmokers, with lower baseline oxygen levels, and they are less responsive to oxygen in general. They produce significant amounts of mucus, which can clog the breathing tube and make it harder to give anesthetic gas and oxygen. If you smoke, there's nothing I can do about it, of course, but knowing it helps me prepare for what might happen and work around it.
3. Do you have any loose teeth? Can you open your mouth? These go along with the whole intubation theme. If you have teeth that are loose, it is theoretically possible that they could be damaged when the breathing tube is either placed or removed. It is rare but possible. And if you have caps, crowns, veneers, or other expensive work on your teeth, especially the front ones, we need to know that as well for the same reason. And as for opening your mouth, that tells us another very important piece of information. How wide you open your mouth, how big your tongue is, how long and wide your chin is - all of these tell us how easy or how difficult it will likely be to do your intubation.
4. Have you ever been told you snore? Kind of a personal question, huh? Not everyone asks it, but I do, and it tells me about how you'll act right after you fall asleep, before I've done the intubation. If you snore, it means you likely have a lot of extra soft tissue in your mouth which vibrates to cause the snoring, and which can collapse when under anesthesia, causing your airway to obstruct. This can get dangerous very quickly. The snoring question also leads to other issues, most notably obstructive sleep apnea, which also greatly increases the risk of going under anesthesia.
5. Has anyone in your family ever had a problem with anesthesia? Usually the answer we get is along the lines of how someone's mom or grandma threw up after anesthesia, but what we're looking for is a rare, usually hereditary, and potentially fatal reaction to anesthesia known as malignant hyperthermia (MH). People with MH develop extremely high and potentially fatal fever in response to very specific anesthetic agents. If caught in time, it can usually be treated, but it's scary. People with a personal or family history of MH can still receive anesthesia, but we need to know that history beforehand, because the OR and anesthesia machines have to be prepared in a very specific way to ensure safety. Don't worry if you don't know all the details about how your grandfather had some weird reaction to anesthesia 70
years ago. If we're the least bit suspicious, you'll get the safe (called a "non-triggering") anesthetic.
6. Do you drink? Use drugs? This is really important to answer truthfully, because lying can literally mean the difference between remembering surgery or not - or between life and death. If you drink alcohol heavily, the amount of anesthesia you require to stay asleep and have amnesia of the surgery is increased. Makes sense, huh? So tell us. As for drugs, they too increase your tolerance to anesthesia, especially heroin or other opioids. The real dangerous one, though, is cocaine. Cocaine sensitized and desensitizes your brain to certain drugs in dangerous ways. Most notably, cocaine in combination with certain blood pressure meeds used in anesthesia can cause extremely high, potentially fatally high, blood pressure increases. Or it can cause the blood pressure to sink to nothing, extremely resistant to all but the strongest drugs. If you use cocaine, we've gotta know that! I don't care or judge how you live your life; I just don't want you to die while receiving anesthesia.
7. How tall are you? How much do you weigh? No, we're not trying to be nosy. A lot of the drugs we give are dosed based on your weight, some on your "ideal" weight, but most on your actual weight. It just helps us be accurate with our drug dosing.
Saturday, August 27, 2011
Epidurals: advice and hints for moms-to-be
So you're on your way to the hospital to have your baby, and you are determined to have an epidural. Not that you don't already have a zillion things on your mind at this point, but here are some things to keep in mind to help make that epidural experience a positive one:
1. Tell your obstetrician and anesthesiologist about any medical issues you may have. This is soooooooo important I can't overstate it. The most important thing with an epidural is to ensure a comfortable and SAFE experience for you and your baby. Whoever your anesthesiologist will be needs to know all about your medical issues. Certain ones are particularly important to us: problems with high blood pressure during pregnancy? That tells us about risk of pre-eclampsia and possible low platelet counts. Are you taking any blood-thinning medications? Sometimes women at risk for blood clots will be on Lovenox, an anticoagulant given as a once or twice daily injection. If that's the case, the epidural placement needs to be timed around the doses. Sometimes the anesthesiologist may choose not to place it.
Other medical issues worth mentioning are anything to do with your back. If you have structural issues with your back, ie scoliosis, history of back surgery (with or without instrumentation), or simply chronic low back pain, we need to know. All of those things make placing an epidural technically difficult and may potentially decrease its effectiveness. In those situations I'm willing to try the epidural if the woman goes into it with open eyes and full knowledge that it may not work, and that I'll err on the side of stopping before doing
any harm.
2. Be nice. I know it's easier said than done when you're in the worst pain of your life, but try. Your anesthesiologist is doing the best they can, and if they're not there five minutes after you called, its probably because they're putting someone else's epidural...
3. Have the room as empty as you can possibly make it. In some hospitals, like Northwestern, the only three people in the room were the anesthesiologist, the nurse, and the patient. No dads or significant others were allowed. It's not being mean; there are practical considerations at work. First, it's a sterile procedure which means the room should be as clean and clutter free as possible. Second, if a dad faints at the (undoubtedly disconcerting) sight of a large needle in his wife's back, no one is there to help him. The nurse and anesthesiologist are obligated to the mother first. There are stories of dads fainting, hitting their heads, and going to surgery for an intracranial bleed. Third, frankly, it's unsettling having someone you don't know breathing down your neck, looking at what you're doing, or worse yet, telling you what to do.
Where I work now, the policy is up to the individual doctor. I let the dads stay if they insist, but I ask them to stand in front of the mom and hold her hand, comfort her, keep her sitting still, etc.
4. Try to hold still as the epidural is being placed. Let me preface this by saying that I am the biggest pansy on earth when it comes to pain, as are most guys. I wouldn't last 10 minutes in labor. I joke with patients that if dads had the childbearing responsibilities, the human race would've died out thousands of years ago.
That being said, it is incredibly disconcerting for me (and dangerous for you) if you move while I have a large needle in your back, within an inch or so of your spinal cord. Bad things can happen. So try really, really, really hard not to move. Labor must hurt something awful, because women, even the most squeamish ones, eventually sit amazingly still if it means the difference between getting or not getting an epidural. Just gimme five more minutes and your pain will be so much better...
5. If you're at an academic medical center, don't ask an attending to do you your epidural. The falsely enlightened ones who would come to Northwestern when I was a resident would do this, and besides being annoying, it was barking up the wrong tree. By the time I was a senior resident, I had placed literally 400 epidurals, all in a four month span. Any of the attending physicians I was working with had placed...nowhere near that many. They're way too busy supervising and doing administrative tasks and are out of practice. With all due respect to my old attendings, if you must ask someone to place your epidural ask a senior resident, or if you're really savvy, an OB fellow if there are any. Generally, though, a good old junior resident will do the job just fine.
6. Unless you're trying to go without, get the epidural as soon as you can. I'm sure any OB reading this will have a fit, but I still think it's a good idea. Before, the wisdom was that getting an epidural before you were 4 centimeters dilated would slow labor and increase the risk of c-section. But several studies have shown (including one that was completed at Northwestern, by the way) that that is not the case. You'll be comfortable for longer, and should things go awry, the epidural is there for a c-section if needed.
7. The longer you wait, the harder it is to get the epidural. The reason is simple. As your cervical dilation increases and contractions get more intense, they hurt more and it's a lot harder to sit still when the epidural is being placed. Also the strength and intensity of the contractions then are such that it is difficult to get full and quick relief from the epidural. But there's a happy corollary to this one:
8. It's never too late to get the epidural. At least it's never too late from the anesthesiologist perspective. Again, if you can sit still, we can try to place it. I remember on one occasion as a resident where I was asked to place an epidural in a woman who was pushing. They were concerned she would need help delivering by forceps and didn't want her to be uncomfortable. So she stopped pushing, sat up for the epidural, and when she got it, kept on pushing. Amazing. Now if the OB doesn't want it for their own set of medical reasons, that's another story...
9. Don't expect a miracle. In some ways, epidural anesthesia is burdened by its own success. One woman tells another who tells another that her epidural was great, and then that woman comes in to deliver, expecting to do so without a hint of pain. Needless to say, that's simply not realistic. We as anesthesiologists can dose the epidural that way, making you so numb you can't feel anything. The problem is that you won't be able to move your legs, and that will make pushing difficult if not impossible and increase the chance of c-section or instrumented delivery. The OB doctors don't like it when we make patients that numb. Sometimes things like spinal anatomy or the position of the baby can cause issues with discomfort that even the best epidural can't completely fix. The ideal is to feel the pressure of the contractions, so that you can actively push, but without the pain that came with them before the epidural.
1. Tell your obstetrician and anesthesiologist about any medical issues you may have. This is soooooooo important I can't overstate it. The most important thing with an epidural is to ensure a comfortable and SAFE experience for you and your baby. Whoever your anesthesiologist will be needs to know all about your medical issues. Certain ones are particularly important to us: problems with high blood pressure during pregnancy? That tells us about risk of pre-eclampsia and possible low platelet counts. Are you taking any blood-thinning medications? Sometimes women at risk for blood clots will be on Lovenox, an anticoagulant given as a once or twice daily injection. If that's the case, the epidural placement needs to be timed around the doses. Sometimes the anesthesiologist may choose not to place it.
Other medical issues worth mentioning are anything to do with your back. If you have structural issues with your back, ie scoliosis, history of back surgery (with or without instrumentation), or simply chronic low back pain, we need to know. All of those things make placing an epidural technically difficult and may potentially decrease its effectiveness. In those situations I'm willing to try the epidural if the woman goes into it with open eyes and full knowledge that it may not work, and that I'll err on the side of stopping before doing
any harm.
2. Be nice. I know it's easier said than done when you're in the worst pain of your life, but try. Your anesthesiologist is doing the best they can, and if they're not there five minutes after you called, its probably because they're putting someone else's epidural...
3. Have the room as empty as you can possibly make it. In some hospitals, like Northwestern, the only three people in the room were the anesthesiologist, the nurse, and the patient. No dads or significant others were allowed. It's not being mean; there are practical considerations at work. First, it's a sterile procedure which means the room should be as clean and clutter free as possible. Second, if a dad faints at the (undoubtedly disconcerting) sight of a large needle in his wife's back, no one is there to help him. The nurse and anesthesiologist are obligated to the mother first. There are stories of dads fainting, hitting their heads, and going to surgery for an intracranial bleed. Third, frankly, it's unsettling having someone you don't know breathing down your neck, looking at what you're doing, or worse yet, telling you what to do.
Where I work now, the policy is up to the individual doctor. I let the dads stay if they insist, but I ask them to stand in front of the mom and hold her hand, comfort her, keep her sitting still, etc.
4. Try to hold still as the epidural is being placed. Let me preface this by saying that I am the biggest pansy on earth when it comes to pain, as are most guys. I wouldn't last 10 minutes in labor. I joke with patients that if dads had the childbearing responsibilities, the human race would've died out thousands of years ago.
That being said, it is incredibly disconcerting for me (and dangerous for you) if you move while I have a large needle in your back, within an inch or so of your spinal cord. Bad things can happen. So try really, really, really hard not to move. Labor must hurt something awful, because women, even the most squeamish ones, eventually sit amazingly still if it means the difference between getting or not getting an epidural. Just gimme five more minutes and your pain will be so much better...
5. If you're at an academic medical center, don't ask an attending to do you your epidural. The falsely enlightened ones who would come to Northwestern when I was a resident would do this, and besides being annoying, it was barking up the wrong tree. By the time I was a senior resident, I had placed literally 400 epidurals, all in a four month span. Any of the attending physicians I was working with had placed...nowhere near that many. They're way too busy supervising and doing administrative tasks and are out of practice. With all due respect to my old attendings, if you must ask someone to place your epidural ask a senior resident, or if you're really savvy, an OB fellow if there are any. Generally, though, a good old junior resident will do the job just fine.
6. Unless you're trying to go without, get the epidural as soon as you can. I'm sure any OB reading this will have a fit, but I still think it's a good idea. Before, the wisdom was that getting an epidural before you were 4 centimeters dilated would slow labor and increase the risk of c-section. But several studies have shown (including one that was completed at Northwestern, by the way) that that is not the case. You'll be comfortable for longer, and should things go awry, the epidural is there for a c-section if needed.
7. The longer you wait, the harder it is to get the epidural. The reason is simple. As your cervical dilation increases and contractions get more intense, they hurt more and it's a lot harder to sit still when the epidural is being placed. Also the strength and intensity of the contractions then are such that it is difficult to get full and quick relief from the epidural. But there's a happy corollary to this one:
8. It's never too late to get the epidural. At least it's never too late from the anesthesiologist perspective. Again, if you can sit still, we can try to place it. I remember on one occasion as a resident where I was asked to place an epidural in a woman who was pushing. They were concerned she would need help delivering by forceps and didn't want her to be uncomfortable. So she stopped pushing, sat up for the epidural, and when she got it, kept on pushing. Amazing. Now if the OB doesn't want it for their own set of medical reasons, that's another story...
9. Don't expect a miracle. In some ways, epidural anesthesia is burdened by its own success. One woman tells another who tells another that her epidural was great, and then that woman comes in to deliver, expecting to do so without a hint of pain. Needless to say, that's simply not realistic. We as anesthesiologists can dose the epidural that way, making you so numb you can't feel anything. The problem is that you won't be able to move your legs, and that will make pushing difficult if not impossible and increase the chance of c-section or instrumented delivery. The OB doctors don't like it when we make patients that numb. Sometimes things like spinal anatomy or the position of the baby can cause issues with discomfort that even the best epidural can't completely fix. The ideal is to feel the pressure of the contractions, so that you can actively push, but without the pain that came with them before the epidural.
Epidurals: what could go wrong?
Like I said in my last post, the benefits of the epidural are obvious. Pain gone. Feel much better. (And, in the event of a change of plans requiring a c-section, it's easy to add more medicine to the epidural to make the woman numb enough to have a c-section comfortably and still be awake to see the baby born).
Now I'm not trying to be a big giant buzz kill, but it's my job, as an anesthesiologist, to think like a pessimist and be prepared for problems and complications. I don't expect them (and, fortunately, have had vanishingly few in my career so far), but just considering their possibilities every time I place a catheter is like my little ritual to ward off the bad vibes. Perhaps this knowledge can work for you in the same way. However, if you are someone who is scared witless (or something else rhyming with witless) by knowing too much, then read no further. My intent is not to frighten people out of getting epidurals but to help them enter the procedure realizing the extent of its invasiveness and the things that might (but honestly, probably won't) go wrong.
Just to be simple and organized, I put them in list form.
What could go wrong with your epidural?
1. Infection. That's why it's a sterile procedure, where we wash our hands beforehand, clean your back with sterile soap, then we put on sterile gloves to open a sterile epidural kit. We wear masks and surgical caps for good measure. Infection, fortunately, is incredibly rare nowadays. But the epidural catheter tip is within a centimeter of the spinal cord. If it's dirty, infection can happen, and needless to say, it's NOT a good place to be infected. That's why any anesthesiologist worth their salt takes sterile technique very, very seriously.
2. Bleeding. Again, bleeding is rare unless you have a condition, congenital or acquired, that predisposes you to bleeding. A woman who is suspected of being pre-eclamptic can have low platelet counts, ones this can change quickly. If that is the case, your anesthesiologist will want to see a recent platelet count before placing an epidural. In the rare cases bleeding occurs, it is usually secondary to the catheter being put it or taken out, in combination with some other intrinsic bleeding issue. Epidural bleeding is bad for obvious reasons - it can cause compression of the spinal cord and neurologic compromise. Did I mention how incredibly rare bleeding and infection are? In three years of training, during which about 28,000 deliveries occurred at my training program, I only know of one epidural abscess or bleed. And even there, it wasn't certain if the epidural caused the problem...
3. Nerve injury. This is even rarer than the first two complications, because the epidural by definition doesn't touch nerves or nerve roots. In a combined spinal/epidural, the spinal needle can graze a nerve root as it enters the dural sac, but that is rare and even when it happens, the needle is so small that it almost never causes even the most transient of symptoms.
4. Nerve palsy. This is totally different from direct nerve injury from anesthetic or a needle. Anesthesia plays an indirect role in this, however, though at times when I was a resident we were blamed more directly than we deserved. Nerve palsies, usually femoral or obturator nerve palsies, occur when the nerves from the low lumbar and sacral roots are compressed for a prolonged period of time by the fetal head. It is rare, but when it happens, the woman doesn't know it until afterwards because, of course, she was numb from the epidural as the nerve compression was occurring. I've also heard of numbness in the legs, feet, and lateral thighs from simply being in stirrups, especially if the woman pushed for a long time. Again, it's not a direct result of anesthesia, but the woman often doesn't know until after the epidural has worn off that she has a numbness in the area in question.
5. The finder needle gets pushed too far and enters the dura. This is the dreaded "wet-tap.". Simply put, this happens when, for whatever reason (difficult anatomy, patient movement, operator error and/or inexperience, etc.), the anesthesiologist pushes the large finder needle too far. Instead of stopping at the epidural space behind the dura, the needle gets pushed through the dura and into the sac of spinal fluid. This in and of itself is not a huge problem. The procedure is still sterile and infection is still rare, and the catheter can be placed and threaded at another level if needed. The problem is afterwards.
When the dural lining is pierced by a large needle like that, it can cause a severe headache afterwards. Classically, it is a positional headache. It is worst when sitting up, when the pain is usually in the occiput, back of the neck, and the forehead. It is thought that the hold in the dura causes a leakage of spinal fluid and a tension on the dural linings in the brain. The headache improves significantly when lying down. Within a week to 10 days, the headache almost always resolves on its own; the problem is that when a new mother is at home with an infant, being confined to bed, lying down, is just not an option. So this kind of headache (known as a postdural puncture headache) is treated proactively when it occurs, with IV fluids, caffeine intake, and oral analgesics. If those don't work, the anesthesiologist can be called in to do a procedure called an epidural blood patch, to close, as it were, the hole in the dura. The success rates with the blood patch are very high.
6. The epidural is difficult for the anesthesiologist to place. The first five things on this list are more serious; the next few are mostly inconveniences and annoyances. Getting an epidural requires sitting in a very uncomfortable position, slouched over with your lower back protruding out - very difficult to do with a full term uterus, not to mention a contraction every two or three minutes. When the poor woman is forced to sit in that position for a half hour or more, it can be tough on everyone. Unless there is a medical reason why the woman really should get an epidural, I'll let her choose if I'm struggling to place it. If I have been trying for a half hour to get an epidural, my telling her how great she'll feel later is sure to fall on deaf ears.
A lot of things can contribute to technical difficulties with epidurals, like abnormal bony anatomy (scoliosis, previous surgery, etc), but since the epidural is placed by feel, the biggest obstacle to epidural placement is...yes, obesity. You know those people who are so skinny you can see the bones in their back? Those people are easy to put epidurals in, because their landmarks are easy to see. If your back is covered with a lot of...um, adipose tissue, the bony landmarks of the back are hard (sometimes impossible) to feel, and placing the epidural can be a crapshoot. Oh sure, once in a while you'll find the thin patient with an amorphous, dough-like back, and the obese patient with easily palpable landmarks, but in general, if someone is obese, it greatly increases the chance of difficult epidural placement, which leads to the next two things on the list...
7. Your back is sore afterwards. My wife had her epidural put in by one of my old attendings. 1 pass with the needle and the epidural was in, and it worked great. Even in that total best-case scenario, she said her back felt sore and strange for several months afterwards, right in the spot where she got the epidural. If getting your epidural was difficult for the anesthesiologist for whatever reason and you were poked more than once, you'll probably be a little sore too.
8. The epidural just doesn't work right. All kinds of things fall into this category. The catheter could fall out at some point because it wasn't taped securely. The epidural makes you numb only on one side, or doesn't work at all. The anesthesiologist's soluton in some of those cases is to simply give more local anesthetic through the epidural. Sometimes that works. Sometimes it doesn't. In those situations where all else fails, the dilemma is the same; should you just make do, or is it worth it to have the anesthesiologist try to place it again? That's a call only you and your anesthesiologist can make.
This is just a partial list. I'm sure I missed a few ones, and there are some other crazy obscure things that I won't mention, but these are the big things to watch out for...
Now I'm not trying to be a big giant buzz kill, but it's my job, as an anesthesiologist, to think like a pessimist and be prepared for problems and complications. I don't expect them (and, fortunately, have had vanishingly few in my career so far), but just considering their possibilities every time I place a catheter is like my little ritual to ward off the bad vibes. Perhaps this knowledge can work for you in the same way. However, if you are someone who is scared witless (or something else rhyming with witless) by knowing too much, then read no further. My intent is not to frighten people out of getting epidurals but to help them enter the procedure realizing the extent of its invasiveness and the things that might (but honestly, probably won't) go wrong.
Just to be simple and organized, I put them in list form.
What could go wrong with your epidural?
1. Infection. That's why it's a sterile procedure, where we wash our hands beforehand, clean your back with sterile soap, then we put on sterile gloves to open a sterile epidural kit. We wear masks and surgical caps for good measure. Infection, fortunately, is incredibly rare nowadays. But the epidural catheter tip is within a centimeter of the spinal cord. If it's dirty, infection can happen, and needless to say, it's NOT a good place to be infected. That's why any anesthesiologist worth their salt takes sterile technique very, very seriously.
2. Bleeding. Again, bleeding is rare unless you have a condition, congenital or acquired, that predisposes you to bleeding. A woman who is suspected of being pre-eclamptic can have low platelet counts, ones this can change quickly. If that is the case, your anesthesiologist will want to see a recent platelet count before placing an epidural. In the rare cases bleeding occurs, it is usually secondary to the catheter being put it or taken out, in combination with some other intrinsic bleeding issue. Epidural bleeding is bad for obvious reasons - it can cause compression of the spinal cord and neurologic compromise. Did I mention how incredibly rare bleeding and infection are? In three years of training, during which about 28,000 deliveries occurred at my training program, I only know of one epidural abscess or bleed. And even there, it wasn't certain if the epidural caused the problem...
3. Nerve injury. This is even rarer than the first two complications, because the epidural by definition doesn't touch nerves or nerve roots. In a combined spinal/epidural, the spinal needle can graze a nerve root as it enters the dural sac, but that is rare and even when it happens, the needle is so small that it almost never causes even the most transient of symptoms.
4. Nerve palsy. This is totally different from direct nerve injury from anesthetic or a needle. Anesthesia plays an indirect role in this, however, though at times when I was a resident we were blamed more directly than we deserved. Nerve palsies, usually femoral or obturator nerve palsies, occur when the nerves from the low lumbar and sacral roots are compressed for a prolonged period of time by the fetal head. It is rare, but when it happens, the woman doesn't know it until afterwards because, of course, she was numb from the epidural as the nerve compression was occurring. I've also heard of numbness in the legs, feet, and lateral thighs from simply being in stirrups, especially if the woman pushed for a long time. Again, it's not a direct result of anesthesia, but the woman often doesn't know until after the epidural has worn off that she has a numbness in the area in question.
5. The finder needle gets pushed too far and enters the dura. This is the dreaded "wet-tap.". Simply put, this happens when, for whatever reason (difficult anatomy, patient movement, operator error and/or inexperience, etc.), the anesthesiologist pushes the large finder needle too far. Instead of stopping at the epidural space behind the dura, the needle gets pushed through the dura and into the sac of spinal fluid. This in and of itself is not a huge problem. The procedure is still sterile and infection is still rare, and the catheter can be placed and threaded at another level if needed. The problem is afterwards.
When the dural lining is pierced by a large needle like that, it can cause a severe headache afterwards. Classically, it is a positional headache. It is worst when sitting up, when the pain is usually in the occiput, back of the neck, and the forehead. It is thought that the hold in the dura causes a leakage of spinal fluid and a tension on the dural linings in the brain. The headache improves significantly when lying down. Within a week to 10 days, the headache almost always resolves on its own; the problem is that when a new mother is at home with an infant, being confined to bed, lying down, is just not an option. So this kind of headache (known as a postdural puncture headache) is treated proactively when it occurs, with IV fluids, caffeine intake, and oral analgesics. If those don't work, the anesthesiologist can be called in to do a procedure called an epidural blood patch, to close, as it were, the hole in the dura. The success rates with the blood patch are very high.
6. The epidural is difficult for the anesthesiologist to place. The first five things on this list are more serious; the next few are mostly inconveniences and annoyances. Getting an epidural requires sitting in a very uncomfortable position, slouched over with your lower back protruding out - very difficult to do with a full term uterus, not to mention a contraction every two or three minutes. When the poor woman is forced to sit in that position for a half hour or more, it can be tough on everyone. Unless there is a medical reason why the woman really should get an epidural, I'll let her choose if I'm struggling to place it. If I have been trying for a half hour to get an epidural, my telling her how great she'll feel later is sure to fall on deaf ears.
A lot of things can contribute to technical difficulties with epidurals, like abnormal bony anatomy (scoliosis, previous surgery, etc), but since the epidural is placed by feel, the biggest obstacle to epidural placement is...yes, obesity. You know those people who are so skinny you can see the bones in their back? Those people are easy to put epidurals in, because their landmarks are easy to see. If your back is covered with a lot of...um, adipose tissue, the bony landmarks of the back are hard (sometimes impossible) to feel, and placing the epidural can be a crapshoot. Oh sure, once in a while you'll find the thin patient with an amorphous, dough-like back, and the obese patient with easily palpable landmarks, but in general, if someone is obese, it greatly increases the chance of difficult epidural placement, which leads to the next two things on the list...
7. Your back is sore afterwards. My wife had her epidural put in by one of my old attendings. 1 pass with the needle and the epidural was in, and it worked great. Even in that total best-case scenario, she said her back felt sore and strange for several months afterwards, right in the spot where she got the epidural. If getting your epidural was difficult for the anesthesiologist for whatever reason and you were poked more than once, you'll probably be a little sore too.
8. The epidural just doesn't work right. All kinds of things fall into this category. The catheter could fall out at some point because it wasn't taped securely. The epidural makes you numb only on one side, or doesn't work at all. The anesthesiologist's soluton in some of those cases is to simply give more local anesthetic through the epidural. Sometimes that works. Sometimes it doesn't. In those situations where all else fails, the dilemma is the same; should you just make do, or is it worth it to have the anesthesiologist try to place it again? That's a call only you and your anesthesiologist can make.
This is just a partial list. I'm sure I missed a few ones, and there are some other crazy obscure things that I won't mention, but these are the big things to watch out for...
Epidurals: What's going on back there?
As promised, I wanted to talk a bit about the technical aspects of epidural anesthesia. At some point I'll try to post pictures; they'll help quite a bit.
First a quick anatomy lesson is needed. So you have a brain and a spinal cord, as well as nerve roots that come out of each side of the spinal cord, between each of the 24 vertebrae that we all possess. This constitutes your central nervous system (CNS). The whole CNS is bathed in cerebrospinal fluid that is itself contained in a bag, as it were. That bag, that lining of the spinal cord and brain, is the dura mater, or just dura for short.
As I said before, the spinal cord has nerve roots that come off on each side at each vertebral level, all the way down to the sacrum, the middle bone of the pelvis. The spinal cord itself, though, doesn't extend all the way down to the pelvis, though; it stops at the L1 or L2 vertebra in most people, ie halfway down your lower back. The dural sac of fluid that envelops then whole CNS extends much further down. So past your L2 vertebra, the dural sac of fluid contains nothing but spinal fluid and nerve roots, just floating freely therein.
What's the point? The point is that when I (or any other anesthesia practitioner) is putting in an epidural, I put it in very low in the back, lower than the point where the spinal cord actually ends. The usual spot is between the 3rd and 4th lumbar vertebrae, or L3-4 for short. Sometimes due to technical considerations, I will go one level higher or lower, but never higher than L2. First of all, obviously, it's much safer to put in the epidural lower in the back, and second, the pain fibers activated during labor come from a wide range of nerve roots, and the L3-4 location is well in the middle of that.
To understand the epidural further we need to look at the name of the procedure - epi-dural. The prefix "epi" means "on" or "against". The epidural catheter place by the anesthesiologist does not rest on the spinal cord; instead it rests against the dural sac that surrounds the spinal cord. So it never actually touches nerves, and there is an added element of safety because of that.
To get to the epidural space just outside the dural sac requires using a big needle called a Tuohy needle, which is inserted (after numbing the skin with local anesthetic), in between the lumbar vertebrae, usually the L3-4 space as I said before. Then, once the skin is numb and the needle is in place in the back, I advance it slowly, while I have it hooked up to a syringe filled with air. What's this for? Well, the spaces between the vertebrae are populated by a number of very firm ligaments, and these ligaments help maintain the integrity of the spine. For the anesthesiologist, they provide resistance when the air filled syringe is pushed against them. As the needle is pushed inward, the resistance is felt when pushing on the air-filled syringe - until the tip of the needle enters the area right outside the dura. That's right, it's the epidural space. I guess technically anatomists don't consider it a "space" because there's really nothing in there except a few veins. This is key, because while I'm pushing on the air-filled syringe and advancing my needle, that epidural "space" feels completely different. Suddenly there's no resistance, and that's how I tell I'm in the right spot.
At that point that's where I can do one of two things, either placing the epidural catheter through the needle, or sticking a long, thin needle through the thicker needle to pierce the dura. The latter is called a combined spinal-epidural, which is how I was trained. Through this tiny needle, I put a small dose of narcotic and local anesthetic into the sac surrounding the CNS. Then I withdraw the small needle and thread the catheter through the larger Tuohy needle. The dural hole created by the spinal needle is small enough that the epidural catheter won't go through it.
The epidural doesn't go that far into the back. Usually it is about 4 or 5 centimeters deep to get to the epidural space, then the catheter is inserted another 4 to 5 centimeters into the space. So a total of 8 to 10 centimeters of catheter is left inside for the duration of labor. It's deep enough that it freaks some people out when I pull the catheter later and they see how deep it was, but not terribly deep.
The epidural catheter is hollow and wire reinforced, which is important because it means medication can be give through it, namely local anesthetic which can keep the woman comfortable throughout her labor and delivery. After giving a small dose of local anesthetic mixed with epinephrine through the catheter to make sure it hasn't inadvertently entered a vein (appropriately, this is called a "test dose"), the catheter is attached to a small pump that administers a continuous flow of local anesthetic up to and through the time the woman delivers.
So that's it. If things go smoothly, from the time I infiltrate the skin with local anesthesia to the time I thread the epidural catheter can be as short as a couple of minutes. Others may be even faster. Speed is key, not just because the woman is in such pain, but going fast makes it possible to (try to) time the epidural placement in between contractions. Now if there are technical difficulties, then things can take longer. A lot longer. That leads me to my next topic. Everyone knows the benefits to getting the epidural; how about the risks? It is empirically a very safe procedure, but it is still worthwhile to think about what could go wrong...
First a quick anatomy lesson is needed. So you have a brain and a spinal cord, as well as nerve roots that come out of each side of the spinal cord, between each of the 24 vertebrae that we all possess. This constitutes your central nervous system (CNS). The whole CNS is bathed in cerebrospinal fluid that is itself contained in a bag, as it were. That bag, that lining of the spinal cord and brain, is the dura mater, or just dura for short.
As I said before, the spinal cord has nerve roots that come off on each side at each vertebral level, all the way down to the sacrum, the middle bone of the pelvis. The spinal cord itself, though, doesn't extend all the way down to the pelvis, though; it stops at the L1 or L2 vertebra in most people, ie halfway down your lower back. The dural sac of fluid that envelops then whole CNS extends much further down. So past your L2 vertebra, the dural sac of fluid contains nothing but spinal fluid and nerve roots, just floating freely therein.
What's the point? The point is that when I (or any other anesthesia practitioner) is putting in an epidural, I put it in very low in the back, lower than the point where the spinal cord actually ends. The usual spot is between the 3rd and 4th lumbar vertebrae, or L3-4 for short. Sometimes due to technical considerations, I will go one level higher or lower, but never higher than L2. First of all, obviously, it's much safer to put in the epidural lower in the back, and second, the pain fibers activated during labor come from a wide range of nerve roots, and the L3-4 location is well in the middle of that.
To understand the epidural further we need to look at the name of the procedure - epi-dural. The prefix "epi" means "on" or "against". The epidural catheter place by the anesthesiologist does not rest on the spinal cord; instead it rests against the dural sac that surrounds the spinal cord. So it never actually touches nerves, and there is an added element of safety because of that.
To get to the epidural space just outside the dural sac requires using a big needle called a Tuohy needle, which is inserted (after numbing the skin with local anesthetic), in between the lumbar vertebrae, usually the L3-4 space as I said before. Then, once the skin is numb and the needle is in place in the back, I advance it slowly, while I have it hooked up to a syringe filled with air. What's this for? Well, the spaces between the vertebrae are populated by a number of very firm ligaments, and these ligaments help maintain the integrity of the spine. For the anesthesiologist, they provide resistance when the air filled syringe is pushed against them. As the needle is pushed inward, the resistance is felt when pushing on the air-filled syringe - until the tip of the needle enters the area right outside the dura. That's right, it's the epidural space. I guess technically anatomists don't consider it a "space" because there's really nothing in there except a few veins. This is key, because while I'm pushing on the air-filled syringe and advancing my needle, that epidural "space" feels completely different. Suddenly there's no resistance, and that's how I tell I'm in the right spot.
At that point that's where I can do one of two things, either placing the epidural catheter through the needle, or sticking a long, thin needle through the thicker needle to pierce the dura. The latter is called a combined spinal-epidural, which is how I was trained. Through this tiny needle, I put a small dose of narcotic and local anesthetic into the sac surrounding the CNS. Then I withdraw the small needle and thread the catheter through the larger Tuohy needle. The dural hole created by the spinal needle is small enough that the epidural catheter won't go through it.
The epidural doesn't go that far into the back. Usually it is about 4 or 5 centimeters deep to get to the epidural space, then the catheter is inserted another 4 to 5 centimeters into the space. So a total of 8 to 10 centimeters of catheter is left inside for the duration of labor. It's deep enough that it freaks some people out when I pull the catheter later and they see how deep it was, but not terribly deep.
The epidural catheter is hollow and wire reinforced, which is important because it means medication can be give through it, namely local anesthetic which can keep the woman comfortable throughout her labor and delivery. After giving a small dose of local anesthetic mixed with epinephrine through the catheter to make sure it hasn't inadvertently entered a vein (appropriately, this is called a "test dose"), the catheter is attached to a small pump that administers a continuous flow of local anesthetic up to and through the time the woman delivers.
So that's it. If things go smoothly, from the time I infiltrate the skin with local anesthesia to the time I thread the epidural catheter can be as short as a couple of minutes. Others may be even faster. Speed is key, not just because the woman is in such pain, but going fast makes it possible to (try to) time the epidural placement in between contractions. Now if there are technical difficulties, then things can take longer. A lot longer. That leads me to my next topic. Everyone knows the benefits to getting the epidural; how about the risks? It is empirically a very safe procedure, but it is still worthwhile to think about what could go wrong...
The universal anesthesia experience...
Now that I have talked about delving into the whole process of general anesthesia, I want to begin by talking about an anesthetic experience most mothers in America have experienced, one where they are very much awake. That, of course, is the epidural, which for most young healthy women is (hopefully, for their sake) their sole exposure to the field of anesthesia. Being that the procedure is performed at such an intense point in a woman's life, both physically and emotionally, you can ask pretty much any woman who has had one about it, and they can probably tell you in exquisite detail about how it went.
"It worked great."
"It only worked on one side."
"The anesthesiologist got it in two minutes."
"It was 3:30 in the morning, my water had just broken, and I was 5 centimeters dilated. I was dying. It took the anesthesiologist a half hour to get it, and he had to try twice." Like in any emotionally charged moment, the details stick out clearly even years later.
Whatever the case, most of the women who got one end saying something along the lines of "it was awesome".
Surprisingly, to me anyway, not a lot of male anesthesioogists I have worked with in the past like OB anesthesia. I'm not sure why, because I enjoy it a lot. My wife and I have a son who was born at the end of my residency under some crazy circumstances, but that's a whole other story. I mention it because I remember how excited and, well, alive I felt around the time our son was born. It ranks as one of the most memorable days of my life, and for most people I see in the OB ward, it is that kind of day for them too. It's a really cool thing, in my opinion, to be a part of that.
Another reason I like OB anesthesia so much is that I'm impatient. Let me explain. When I walk into the room of a woman in labor, she's absolutely miserable, writhing in agony, cursing, screaming, grimacing, or all of those. If everything goes well, twenty minutes later, when I walk out of the the room, she's happy, smiling, comfortable, and really, really, really grateful. What's better than that? In my world of anesthesia, not much. It's immediate gratification in its purest form, and I have done something good for someone as well.
But just in case I start feeling a bit too good about myself and my epidural abilities, I remember this: my role in the whole childbirth process is not medically necessary. Of course, any woman who can remember how awful labor was might disagree, but the fact of the matter is that women delivered babies for thousands of years before epidural anesthesia. At Northwestern, where I trained, 90% of the women, conservatively, got epidurals. A lot of things are factored into that, such as the wishes of the obstetrician, and the patient population. We had a lot of well-to-do patients who pretty much expected the epidural to be a standard part of the birth experience. That was its own set of issues, good and bad, and that's a story for another time.
In future blogs I'm going to get into a little bit of the technical stuff about epidurals, (without trying to get too boring), and then I'll just give a list of useful advice for moms-to-be who are considering getting an epidural.
"It worked great."
"It only worked on one side."
"The anesthesiologist got it in two minutes."
"It was 3:30 in the morning, my water had just broken, and I was 5 centimeters dilated. I was dying. It took the anesthesiologist a half hour to get it, and he had to try twice." Like in any emotionally charged moment, the details stick out clearly even years later.
Whatever the case, most of the women who got one end saying something along the lines of "it was awesome".
Surprisingly, to me anyway, not a lot of male anesthesioogists I have worked with in the past like OB anesthesia. I'm not sure why, because I enjoy it a lot. My wife and I have a son who was born at the end of my residency under some crazy circumstances, but that's a whole other story. I mention it because I remember how excited and, well, alive I felt around the time our son was born. It ranks as one of the most memorable days of my life, and for most people I see in the OB ward, it is that kind of day for them too. It's a really cool thing, in my opinion, to be a part of that.
Another reason I like OB anesthesia so much is that I'm impatient. Let me explain. When I walk into the room of a woman in labor, she's absolutely miserable, writhing in agony, cursing, screaming, grimacing, or all of those. If everything goes well, twenty minutes later, when I walk out of the the room, she's happy, smiling, comfortable, and really, really, really grateful. What's better than that? In my world of anesthesia, not much. It's immediate gratification in its purest form, and I have done something good for someone as well.
But just in case I start feeling a bit too good about myself and my epidural abilities, I remember this: my role in the whole childbirth process is not medically necessary. Of course, any woman who can remember how awful labor was might disagree, but the fact of the matter is that women delivered babies for thousands of years before epidural anesthesia. At Northwestern, where I trained, 90% of the women, conservatively, got epidurals. A lot of things are factored into that, such as the wishes of the obstetrician, and the patient population. We had a lot of well-to-do patients who pretty much expected the epidural to be a standard part of the birth experience. That was its own set of issues, good and bad, and that's a story for another time.
In future blogs I'm going to get into a little bit of the technical stuff about epidurals, (without trying to get too boring), and then I'll just give a list of useful advice for moms-to-be who are considering getting an epidural.
Hello and welcome
Good morning all,
My name is Ben and I am an anesthesiologist living and working in the Chicago area. My job, by nature, is enshrouded in mystery. Like all doctors, I have done many year of training and have steadfastly dedicated myself to practicing medicine in the best way I know how. Unlike other doctors, though, my patients have to take me at my word when I tell them that, because they're sleeping while I am taking care of them.
So what is it that I (and 46,000 other anesthesiologists nationwide, not to mention thousands of CRNAs) do while you the patient are sleeping? Millions of surgeries, and thus millions of anesthetics, are done in the United States each year, and the overwhelming majority of them do just fine. General anesthesia is truly one of the most amazing advances in modern medicine, allowing for painless surgery and the endless array of invasive procedures that doctors are now capable of performing. Once quite dangerous for even the healthy patients, time and technology have sharpened and refined it considerably to the point that general anesthesia, even on the sickest patients, is a very safe endeavor.
In some ways, though, anesthesia, like all of modern medicine, has become a victim of its own success, so to speak. Their record of safety, especially recently, has become so good that the general public takes for granted how fascinatingly complex - and dangerous - even the most "routine" anesthetic can be. Two years ago, when Michael Jackson died as a result of the misuse of the common anesthetic drug propofol, this danger raised its ugly head, and with tragic consequences. The buzz of publicity that followed was particularly revealing to me in that it showed how little people really understood about anesthesia and what I do for a living. Two years later, I encounter that misunderstanding every day, in every place - comments I hear from patients, sound bites on TV and radio.
Even many of the surgeons I work with don't know a lot about what I'm doing back there on the other side of the surgical drapes. As long as the patient is safe, immobile during surgery, and wakes up at the end, that's all that matters to them. That's no knock on the surgeons; their focus is on their operation, and conversely, I don't pretend to know how to perform any of the operations I am privileged to participate in on a daily basis. If they are focused too much on me, they can't perform their best operation, and it isn't good for anybody.
The biggest reason I have started this blog is to help demystify exactly what goes on when the patient is asleep during surgery. I won't give a step-by-step guide on how to give anesthesia; it takes years of study and training to accomplish that. What I can do is provide an insider's perspective on the complex process that is anesthesiology. Even the simplest general anesthetic involves bringing a patient perilously close to death, controlling all aspects of their physiology while they sleep, all the while maintaining their immobility, minimizing their discomfort, and ensuring their amnesia of the operation. It is a task I, and thousands of other anesthesia providers like me, take seriously. Over the course of this blog, I hope to shed some light on how and why we do things, and in doing so, I can hopefully unmask some of the mystery - and allay most of the fears - that patients feel before undergoing anesthesia.
My name is Ben and I am an anesthesiologist living and working in the Chicago area. My job, by nature, is enshrouded in mystery. Like all doctors, I have done many year of training and have steadfastly dedicated myself to practicing medicine in the best way I know how. Unlike other doctors, though, my patients have to take me at my word when I tell them that, because they're sleeping while I am taking care of them.
So what is it that I (and 46,000 other anesthesiologists nationwide, not to mention thousands of CRNAs) do while you the patient are sleeping? Millions of surgeries, and thus millions of anesthetics, are done in the United States each year, and the overwhelming majority of them do just fine. General anesthesia is truly one of the most amazing advances in modern medicine, allowing for painless surgery and the endless array of invasive procedures that doctors are now capable of performing. Once quite dangerous for even the healthy patients, time and technology have sharpened and refined it considerably to the point that general anesthesia, even on the sickest patients, is a very safe endeavor.
In some ways, though, anesthesia, like all of modern medicine, has become a victim of its own success, so to speak. Their record of safety, especially recently, has become so good that the general public takes for granted how fascinatingly complex - and dangerous - even the most "routine" anesthetic can be. Two years ago, when Michael Jackson died as a result of the misuse of the common anesthetic drug propofol, this danger raised its ugly head, and with tragic consequences. The buzz of publicity that followed was particularly revealing to me in that it showed how little people really understood about anesthesia and what I do for a living. Two years later, I encounter that misunderstanding every day, in every place - comments I hear from patients, sound bites on TV and radio.
Even many of the surgeons I work with don't know a lot about what I'm doing back there on the other side of the surgical drapes. As long as the patient is safe, immobile during surgery, and wakes up at the end, that's all that matters to them. That's no knock on the surgeons; their focus is on their operation, and conversely, I don't pretend to know how to perform any of the operations I am privileged to participate in on a daily basis. If they are focused too much on me, they can't perform their best operation, and it isn't good for anybody.
The biggest reason I have started this blog is to help demystify exactly what goes on when the patient is asleep during surgery. I won't give a step-by-step guide on how to give anesthesia; it takes years of study and training to accomplish that. What I can do is provide an insider's perspective on the complex process that is anesthesiology. Even the simplest general anesthetic involves bringing a patient perilously close to death, controlling all aspects of their physiology while they sleep, all the while maintaining their immobility, minimizing their discomfort, and ensuring their amnesia of the operation. It is a task I, and thousands of other anesthesia providers like me, take seriously. Over the course of this blog, I hope to shed some light on how and why we do things, and in doing so, I can hopefully unmask some of the mystery - and allay most of the fears - that patients feel before undergoing anesthesia.
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