Waking Up Costs

The Ether Way on the Preop Interview

Clark Venable — Thu, 28 Jun 2007 14:54:03 GMT

Right on, brother:

"Long ago, my preop interview became less pre-flight check-list and more gut-check and sniffing for smoke. (I'll write more about sniffing for smoke in another post) Paradoxically perhaps, the most important thing to me is to bond to the patient; it's the second part of that WCW observation. I might do eight or ten cases in a day; the consequence of treating my work as a technical exercise is the risk of inattention and the sort of boredom that drives the desperate discontent that I see in so many of my colleagues."

[The Ether Way]

I'm a Better Anesthesiologist Today Than A Year Ago

Clark Venable — Sun, 06 May 2007 04:00:00 GMT

At the end of this busy week I began to reflect on how this week was different than an average week would have been even a year ago. It was different both for me and for a significant number of my patients. Hopefully, it was as good for patients as it was for me.

For the first ten years after I finished my training I did not believe nerve blocks for extremity surgery were worth doing. Surgeons didn't want to wait for me to do them or for the blocks to 'set up.' Blocks failed a certain amount of the time. There were complications that just didn't happen when 'numbing the big nerve.'

My thoughts on all this changed, not because of a journal article or discussions with a colleague, but because of an article in Wired magazine. The Painful Truth was an article on the use of regional anesthesia to improve medical care to our wounded soldiers in Iraq and Afghanistan:

Now Buckenmaier is leading a group of army doctors and nurses determined, as he puts it, "to drag the military kicking and screaming into the 21st century." His team believes the future of wartime pain control is a new form of anesthesia called a continuous peripheral nerve block, which takes a more targeted approach by switching off only the pain signals coming from the injured limb, leaving patients' vital signs and cortical functions unimpaired.

The applicability to civilian anesthesia was obvious. In my hospital, when someone gets a knee replaced, the surgeon usually blindly injects a large amount of local anesthetic in the general vicinity of the femoral nerve and we dope them up with morphine. Patients are in the hospital for three days largely for pain control issues, all the while at risk for nausea, vomiting, respiratory depression, etc.

I took a second look at regional anesthesia and decided to use it in my practice again. This week two elderly ladies had total shoulder replacements after having interscalene blocks. They were pain free for the rest of that day. Six of my patients had knee replacements after femoral and sciatic blocks. They had no pain until the next morning.

With catheter techniques, these pain-free intervals will be measured in days instead of hours. The surgeons are giving us the time to do these techniques because they are hearing about how good they are for patients at their own national meetings. My colleagues who 'didn't do blocks' have learned to do simple femoral nerve blocks and want to learn others.

It was a good week for me because I love seeing patients do well. It was a good week for my patients (whether they knew it or not) because they trusted me enough to let me poke them with a needle once or twice to make their recovery that much easier. By next year I hope to be placing catheters and doing infusions. Thanks, Trip Buckenmaier.

Acoustic Respiratory Monitoring: What Is It?

Clark Venable — Tue, 17 Apr 2007 04:00:00 GMT

An intriguing press release last week from Masimo (known for their motion artifact-resistant pulse oximeters) begins as follows:

"Masimo, the inventor of Pulse CO-Oximetry and Read-Through Motion and Low Perfusion pulse oximetry, reported that three new independent studies, including one presented the recent International Anesthesiology Research Society (IARS) Clinical & Scientific Congress in Orlando, concluded that Masimo Acoustic Respiratory Monitoring technology (ARM) is "at least as accurate as capnometry" and "significantly more reliable" for monitoring respiration in spontaneously breathing patients."

The release then refers to "an adhesive bioacoustic sensor applied to the patient's neck and connected to a breathing frequency monitor prototype" which in turn accurately monitors respiratory rate.

If this device does what I think it does, it will become the standard of care for post-surgical patients very rapidly. We've been looking for a way to reliably monitor respiratory rate on the floors, once patients are discharge from the recovery room. For example, a patient may receive pain medications from multiple sources, with unpredictable onsets. How do we know their maximum respiratory depression won't happen after they've been delivered to their hospital room?

A patient can receive oxycontin and celebrex orally from a surgeon before their knee replacement surgery, then more fentanyl, morphine, and versed from us (anesthesia). The surgeon may then inject bupivicaine and morphine into the joint at the conclusion of surgery (without necessarily telling the anesthesiologist). I might also do a femoral nerve block to further reduce post-op pain. All of us are trying to do right by the patient but, given the right set of circumstances, are setting them up for significant respiratory depression post-op. The ability to reliably monitor respiratory rate with this new Masimo monitor would be a huge patient safety advance.

The Society for Technology in Anesthesia abstract is here.

March 30, 1842: The First Ether Anesthetic

Clark Venable — Fri, 30 Mar 2007 17:38:02 GMT

Wikipedia

"Although William T.G. Morton is well-known for performing his historic anesthesia on October 18, 1846 in Boston, Massachusetts, C.W. Long is now known to be the first to have used an ether-based anesthesia.

After observing the same effects with ether that were already described by Humphry Davy in 1800 with nitrous oxide, C.W. Long used ether the first time on March 30, 1842 to remove a tumor from the neck of his patient, Mr. James M. Venable. Long subsequently removed a second tumor from Venable and used ether anesthesia in amputations and childbirth. The results of these trials were published several years later (in 1849) after Morton's publication. "

CRNA Independent Practice: Deciding Which Question to Answer

Clark Venable — Thu, 22 Feb 2007 02:17:54 GMT

In doing some more reading on the CRNA independent practice issue, I found what I thought was a curious quote in a Centers for Medicare and Medicaid Services press release from January 17, 2001. The press release is an announcement that Medicare will leave decisions on whether physician supervision of CRNA's is necessary to the States. Here's the quote from the second to the last paragraph:

"There is no evidence that CRNA independent practice would cause adverse outcomes."

I think asserting that there is no evidence that CRNA independent practice would cause adverse outcome is the wrong question to address. I think the question should be, 'is there evidence that CRNA independent practice would be as safe for patients as the present system?' (we're a six sigma specialty, remember).

The Safe Seniors Assurance Study Act of 1999 was to address the issue but it never made it out of committee:

"(1) The Secretary of Health and Human Services shall conduct a study of mortality and adverse outcome rates of medicare patients by providers of anesthesia services. In conducting the study, the Secretary shall analyze the impact of physician supervision of providers of anesthesia services, or lack thereof, on such mortality and adverse outcome rates.

(2) In conducting the study, the Secretary shall consult with appropriate national professional organizations with respect to the methodology of the study, and shall use medicare operating room anesthesia data, adjusted for patient acuity and other relevant scientific variables."

Sounds like a good starting point for this discussion, however...

(Another Reason Why) I Like Desflurane

Clark Venable — Wed, 21 Feb 2007 21:19:55 GMT

I've posted before on why I think the desflurane Tec 6 vaporizer is a good design (it doesn't need to be turned off to be refilled). I'd like to add another reason to the list: it has alarms.

The Desflurane Tec 6 has a 'low agent' alarm and a 'no output' alarm, in addition to the ability to detect when it has been tipped (and therefore shouldn't be used). The other common agent, Sevoflurane, is delivered via a vaporizer that has none of these things. I am personally aware of two cases where no volatile anesthetic was delivered despite the vaporizer being 'open'. Two cases that would have been uneventful if desflurane and a Tec 6 vaporizer had been used. I'm going to ask the Society for Technology in Anesthesia listserv if there is any reason the Sevoflurane vaporizer couldn't have these features.