Going To Sleep Is Free, But

Pre-emptive Patient Positioning

• Categories: Anesthesia practice, Anesthesia Tips
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Many surgeries require the patient to be in a position other than supine (flat on their back) for the surgery to be done. Shoulder surgery, for example, is often done with the patient in a semi-sitting or 'beach chair' position. Certain hip surgeries are done with patients on their side as well. General anesthesia is induced with the patient supine, then people have to move the patient (who is now akin to a very heavy sack of potatoes) into the right position. It's time consuming, risks staff injury, and jeopardizes the airway. The few accidental extubations I've had have occurred when the patient was being moved. Does it have to be this way? If the case is amenable to an LMA, I think the answer is 'no.'

If I'm caring for a patient who will require a general anesthetic and an LMA would be suitable, I've taken to positioning the patient before induction of anesthesia. I then pre-oxygenate, perform an IV induction, and place the LMA. The OR staff and surgeons like it because a) it saves time and b) it saves their backs. I like it because there's no move during which my airway can potentially be compromised (and because it saves time and saves my back). There's a benefit to the patient, too. Namely, they can tell us while awake whether our positioning is comfortable for them. Is the axillary role in the right place? Do they need a pillow under their knees in? Is their bottom up against the back of the table in beach chair? Is their ear properly padded in the lateral position? Think Different (but always, Think Safe).

When can nursing mothers resume breastfeeding after surgery?

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When can nursing mothers resume breastfeeding after surgery?:

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

Why I Like Being An Anesthesiologist

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I've tried to explain to people why I like being an anesthesiologist so much--with difficulty (unfettered access to narcotics, starting my work day at 07:30, having patients ask me if I'm a real doctor, oodels of respect from surgeons and nurses alike are the reasons that usually come to mind). I just ran across something on the web that really helps me understand why. Getting Back To Work: A Personal Productivity Toolkit at kuro5hin.org is an article about procrastination. Now, my favorite motto is 'hard work pays off after a time, but laziness pays off now,' so I was naturally drawn to this article.

The article describes the ideal work experience as being in a state of 'flow' and goes on to outline the kinds of tasks that make it more likely you'll be able to attain it:

Bingo! That's why I like being an anesthesiologist in private practice!

That's also why I like using Conversant to build web sites. When I'm working on a Conversant site, I often reach a state of 'flow.'

[Via 43 Folders]

Triple Lumen Catheters Are Not Volume Lines

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I brought a patient to the operating room recently who had a Type A ascending thoracic aneurysm dissection. She was bleeding into her pericardium and was in tamponade on arrival. She had a radial arterial line that wasn't (in an artery), and two triple lumen central lines--one in a femoral vein and one in an internal jugular vein.

I immediately thought back to my medical school days when I would see patients in the ICU with a GI bleed being transfused with cold, undiluted packed red blood cells through a triple lumen central line....and they were on vasoactive drips for 'hypotension.'

What's my point? Triple lumen catheters are long and narrow (especially compared to Cordis introducer sheaths or products like them made by other manufacturers such as Arrow). Remember the Poiseuille-Hagen equation shows that flow rate is directly proportional to the fourth power of the radius, to the viscosity of the fluid being transfused, and to the pressure gradient established and inversely proportional to the length of the tube. A 9 French introducer sheath can infuse fluid at about 1000 cc/min. Compare that to about 250 cc/min for the 14 gauge lumen of a triple lumen catheter. So it follows, then, that if you need to give someone fluid (like blood) fast, you infuse it through a fat catheter that is short, reduce the viscosity by diluting it and warming it (in the case of packed red blood cells), and apply some pressure by elevating it well above the patient or putting a pressure bag on it. Got it? Good! This might come in handy when you next see a hypovolemic patient...

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

• Categories: Medical Articles, Anesthesia practice, Anesthesia Tips
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BMJ: Parenteral metoclopramide for acute migraine: meta-analysis of randomised controlled trials -- Colman et al. 329 (7479): 1369

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

How Much Midazolam Is Holding Someone's Hand Worth?

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I provided anesthesia for cataract surgery today. For most of today's patients, it was their second eye and they tend to be more nervous the second time. I rediscovered how holding someone's hand is worth at least a milligram or two of midazolam (intravenous sedative).

Luscious Lips

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For longer general anesthetics, anesthesiologists often place a lubricant on the eyes before taping them closed. We tape them closed to avoid corneal abrasions and prevent drying. Lacrilube is the product most commonly used and it contains white soft paraffin, liquid paraffin and lanolin alcohols. Here's the hint: it works great as a lip balm, too! Just a dab on the lips and your patients will roll into the recovery room with shiny, luscious smackers and you'll earn yourself five easy style points, too.

St. Caffeine and Anesthesia

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If you're an anesthesiologist or surgeon, a significant number of your patients are caffeine dependent. Being aware of this fact and planning for it will significantly improve your patient's operative experience. In fact, if you're an anesthesiologist or a surgeon, you're probably caffeine dependent, but that another blog post. In my pre-op visits with patients, I ask if they are regular caffeine drinkers, if so, how much, and what happens if they don't have any caffeine on a given day. For patients that report headaches without daily caffeine intake, I plan on administering caffeine.

The most convenient form pre-op is injectible Caffeine and Sodium Benzoate (though tablets are also available). Our formulation comes in a 2 cc vial, of which each cc contains 121mg of anhydrous caffeine. I think of each cc as being the equivalent of one cup of coffee or one can of Diet Coke. Yes, there are studies. Here's one of them: Prophylactic intravenous administration of caffeine and recovery after ambulatory surgical procedures. The cost? About $3.50 per vial. About the same as a tall latte with extra foam (in Europe). I typically administer one cc IV very slow push, and squirt the other cc into the iv bag.

You know what I think the biggest benefit is? It's not just the lack of headache (they weren't expecting a headache when they came in) it's the feeling that they're being well cared for. Sort of like bringing them a warm blanket. Oh, and the nurses will be very impressed, too.

p.s. the title of this post refers to a song by John Gorka called St. Caffeine:

I've seen the light, oh the light I've seen

I've seen the light of St. Caffeine

Of other drugs I am clean

I pray to you St. Caffeine

I moved this over from my personal blog