Внутривенный наркоз в гинекологии: техника, препараты, побочные эффекты

Относительно недолгий внутривенный наркоз в гинекологии используется часто, потому что именно в этой области медицины много несложных кратковременных операций и процедур (диагностика полости матки, выскабливание, прерывание беременности). И нет смысла давать пациентке глубокий масочный наркоз, если вмешательство длится всего 20-30 минут.

Принцип

Общая внутривенная анестезия тоже позволяет отключать сознание человека, поэтому многие пациенты зря опасаются, что они будут что-то чувствовать и осознавать. Препараты, введенные в вену, начинают действовать моментально, и уже спустя минуту человек спит. А по окончании действия медикаментозного коктейля просыпается.

В гинекологии внутривенная анестезия просто незаменима, потому что это позволяет ставить некоторые несложные операции буквально на поток. Женщина приходит в операционную, ее погружают в наркоз через укол в вену и выполняют вмешательство. Затем пациентку будят и отправляют в палату, чтобы окончательно прийти в себя.

Но в отличие от ингаляционного наркоза, внутривенный не вызывает тяжелых побочных эффектов, поэтому спустя пару часов пациентка уже может идти домой. На ночь в больнице ее оставляют только в крайних случаях, если операция прошла с осложнениями. Сам же внутривенный наркоз редко вызывает какие-то резко негативные реакции.

Кстати! При выполнении гинекологических операций под внутривенным наркозом врач все равно выполняет местное обезболивание операционной зоны, чтобы пациентка не проснулась от боли раньше времени.

Как проводится

Несмотря на простоту проведения внутривенного наркоза, все делает специалист – анестезиолог. Он предварительно проводит с пациенткой беседу, изучает ее медицинскую карту, обращает внимание на показатели давления и пульса. Затем уточняет у гинеколога примерную длительность операции, чтобы рассчитать дозировку наркотической смеси.

1. Пациентка готовится к операции с внутривенным наркозом так же, как к любой другой: сдает все анализы, утром ничего не ест, снимает все украшения.
2. На операционном столе женщину подключают к аппаратам, фиксирующим давление и пульс.
3. Медсестра ставит в вену катетер, а анестезиолог постепенно вводит туда препараты и наблюдает за реакцией пациентки.
4. Когда женщина засыпает, начинается операция. Если вмешательство затягивается, врач может добавить немного препаратов в вену. А иногда наркоз и вовсе проводится болюсным методом: непрерывным поступлением наркотической смеси в вену через капельную систему.
5. По окончании операции пациентку будят обычным способом.

Что ощущает женщина? Ничего. Она просто крепко спит, но не чувствует при этом ни прикосновений врачей, ни болезненных ощущений. Многим даже что-то снится. А сон настолько приятный и эйфорический, что просыпаться зачастую не хочется.

Кстати! Пациенты, которым делают внутривенный наркоз, дышат самостоятельно. Хотя анатомические особенности некоторые пациенток требуют дополнительной установки ларингиальной маски, которая не позволяет языку западать и мешать свободному ходу воздуха.

Если это сложная операция по гинекологии (аборт на позднем сроке, удаление опухолей или органов), то одним только внутривенной анестезией не обойтись. Проводится полноценный масочный наркоз. Но предварительно все равно в вену вводят препараты, которые усыпляют женщину и позволяют не испытывать неприятных ощущений от установки эндотрахеальной трубки.

Препараты

Для анестезии в гинекологии используются те же препараты, что и в других медицинских отраслях. Они комбинируются в разных сочетаниях и дозировках, чтобы получить нужный для конкретной операции коктейль.

• Морфин + тримеперидин. Оптимальная смесь для большинства несложных операций в гинекологии.
• Фентанил + дроперидол. Пациентка засыпает почти моментально. Также наступает частичная миорелаксация.
• Промедол + атропин + феназепам. Избавляет от страха, который может возникнуть у пациентки после пробуждения (если это морально тяжелая гинекологическая операция, например, аборт).
• Также могут использоваться и другие препараты в разных сочетаниях: пропанидид, виадрил, кетамин, оксибутират натрия и др.

Если врач ошибается с дозировкой и дает слишком мало внутривенного наркоза, это заметно по показателям пациентки и по ее реакциям. В этом случае вводится дополнительное количество препаратов. Если же их изначально слишком много, может случиться остановка дыхания, которая моментально купируется путем подключения к аппарату искусственной вентиляции легких. Технически это немного сложнее, но для пациентки ничем не грозит.

Противопоказания

Экстренные операции, от которых зависит жизнь человека, проводятся, несмотря на противопоказания. Но плановые вмешательства по гинекологии могут переноситься при наличии у женщины:

• инфекционных и воспалительных заболеваний;
• сердечно-сосудистой недостаточности;
• острых болезней дыхательных путей.

Беременность является относительным противопоказанием. И если только операция может спасти жизнь будущего ребенка, ее проводят. Вид наркоза (внутривенный, масочный или эпидуральная анестезия) выбирается в зависимости от сложности хирургического вмешательства.

Побочные эффекты

Нельзя сказать, что в гинекологии после внутривенного наркоза пациентки чувствуют себя отлично. Эйфория прослеживается только в первые минуты после пробуждения, а затем может начать болеть и кружиться голова. Многие отмечают, что это напоминает похмелье, когда тошнит, голова тяжелая, хочется поспать, но не получается.

Боли в оперируемой зоне не относятся к побочным эффектам внутривенного наркоза, но они тоже присутствуют. И именно из-за них женщина не может уснуть. Разумеется, ей дают обезболивающее, но его действие рано или поздно заканчивается.

В редких случаях пациентки отходят от внутривенного наркоза очень тяжело и слишком долго. Обычно у них в это же день хватает сил, чтобы самостоятельно добраться до дома. А там постельный режим, отдых и восстановление сил.

90000 Total intravenous anaesthesia (TIVA) 90001 90002 90003 Total intravenous anaesthesia (TIVA) can be defined as a technique of general anaesthesia using a combination of agents given solely by the intravenous route and in the absence of all inhalational agents including nitrous oxide. The intravenous route has been used to administer drugs for hundreds of years and the provision of anaesthesia solely by the intravenous route using chloral hydrate was documented as early as the 1870’s. Thiopentone was introduced into clinical practice in 1934 and made intravenous induction of anaesthesia popular.Propofol was introduced into clinical practice in 1986 and now seems to be taking over that role. It has also become widely used as a component of TIVA. 90004 90002 TIVA has become popular, practical and possible only in relatively recent times. There are two main reasons for this. Firstly, unlike other popular intravenous agents of the past, the pharmacokinetic and pharmacodynamic properties of modern drugs like propofol and the newer synthetic, short acting opioids make them very suitable for administration by continuous infusion.Secondly, new concepts in pharmacokinetic modelling and advances in computer technology have allowed the development of sophisticated delivery systems which make control of anaesthesia given by the intravenous route as straightforward and user friendly as conventional inhalational techniques. 90004 90002 Intravenous drug administration to provide anaesthesia has evolved to become a popular alternative to inhalational anaesthesia. This evolutionary process is a result of improved understanding of pharmacokinetics, pharmacodynamics and the interactions which take place during continuous drug administration.Understanding these processes has facilitated the development of computerised syringe drivers that allow optimal drug selection and combinations. New intravenous drug delivery systems allow anaesthetists to vary anaesthetic depth in response to clinical signs in a manner intuitively similar to conventional volatile systems; thus simplifying the administration of intravenous anaesthesia. The result is an easy to use modern system of providing anaesthesia, which allows rapid, precise and independent control of amnesia, hypnosis and analgesia.90004 90009 90010 90009 Pharmacokinetics and TIVA 90010 90002 Pharmacokinetics is a potentially complex subject but an understanding of the basic concepts in relation to anaesthetic drugs can help to clarify the clinical implications of using a particular drug for TIVA and so assist optimal drug selection and combination. 90004 90002 90016 The science of pharmacokinetics is simply the use of mathematics to describe how the body ‘handles’ particular drugs. Data can be gathered by performing plasma assays of specific drugs after administration (by either single dose or infusion) to examine how the plasma concentration changes over time.There is a mathematical relationship between an administered dose of a drug and the resulting observed changes in plasma concentration. This relationship allows mathematical pharmacokinetic models to be constructed that may then be used to facilitate the calculation of dosing regimens and to guide pharmacotherapeutic management. 90004 90002 The system of intravenous drug delivery used during TIVA must help to achieve the following goals: smooth induction, reliable and titratable maintenance and rapid emergence.In addition, a system that uses the skills the anaesthetist has already learned administering inhalational anaesthetics would seem logical. Target controlled infusion (TCI) devices have been developed to meet these requirements. 90004 90009 90010 90009 Advantages of Target Controlled Infusion (TCI) 90010 90002 A number of infusion device manufacturers have introduced «open» TCI systems for propofol, remifentanil and sufentanil. These new devices are CE marked. If a company believes that their device meets so called «essential requirements» of performance and safety, and if they have an approved quality system in house, they do not need to submit their device for external evaluation by a statutory body.The medical device regulations do not require any collaboration between device and drug manufacturers, and one could argue that this should be required, to ensure that the device contains an appropriate pharmacokinetic model. Since November 2004 in the UK, the only drug that is licensed for administration by TCI is propofol, from Diprifusor TCI systems. Use of «open» TCI systems could be considered as «off label» drug administration, although if drug delivery rates achieved in TCI mode fall within those advocated in existing labelling for (manual) bolus and infusion dosing it could be argued that delivery is in accordance with the prescribing information.Computerised delivery systems 90004 90002 Intravenous maintenance of anaesthesia after induction can be achieved by simple repeated doses. This has the disadvantage of peaks and troughs in drug concentration, which could result on the one hand, in undesirable toxic effects and on the other, in underdosing. The next logical step then is to give the drug by continuous infusion but the disadvantage with that method is the delay to peak effect, which is the equivalent of four or five drug elimination half-lives.If a loading dose is given at the start of a fixed infusion rate, then an initial peak effect is reached more quickly but there is a decrease in concentration at the transition from loading dose to maintenance, due to drug redistribution. This again introduces a risk of underdosing. To avoid this problem, the maintenance regimen must take into account the decline in drug concentration. In the course of a procedure, changes in anaesthetic depth often need to be swift to respond to variations in degree of surgical stimulation.Although changes in a manual infusion rate will cause predictable changes in blood concentration, the delay in reaching the new higher concentration would usually be unacceptable. To increase the blood concentration more quickly a bolus increment followed by a change in infusion rate would have a quicker onset time but the calculations required to select the correct bolus and new infusion rate are fairly complex. They would certainly not be practical for the individual anaesthetist to carry out in the course of an anaesthetic.Reduction in dose has its hazards too; discontinuation of a manual infusion could result in it inadvertently not being switched back on. 90004 90002 90029 One answer to all these problems is a computer driven infusion device programmed with specific propofol pharmacokinetic parameters and used to achieve a pre-set target plasma concentration of drug. Multiple complex calculations are clearly the domain of the microprocessor, which can make this process of administering anaesthesia by TCI analogous to that of controlling volatile anaesthesia.A target level is selected by the anaesthetist on the infusion device for induction and is subsequently adjusted in response to clinical signs to maintain adequate anaesthetic depth. There is no need for a bolus induction dose as it is included in the machine’s calculations when the anaesthetist first sets the initial plasma concentration. Depth of anaesthesia can be changed swiftly in the course of an operation by simply selecting a new target blood concentration, similar conceptually to adjusting a vapouriser during volatile anaesthesia.The microprocessor makes all the relevant calculations of bolus increment or alterations in the infusion rate that are required to achieve, maintain and alter the blood concentration to any target level programmed by the anaesthetist. 90004 90002 90004 90009 The development of Target Controlled Infusion devices 90010 90002 The benefits of TCI have been recognised for some time and computer controlled systems were described in the literature in the late 1980’s. Lack of commercial availability, however, prevented widespread use of these TCI systems.In the case of propofol, various TCI prototypes had been developed over the years using different pharmacokinetic parameter sets. 90004 90002 The availability of short-acting, potent hypnotic and analgesic drugs and modern TCI systems make the process of administering TIVA now a practical and straightforward alternative to conventional inhalational anaesthesia. At the same time, improved understanding of drug kinetics, dynamics and interactions has facilitated optimal drug selection and method of administration, which can be easily tailored to clinical requirements.Rapid and precise titration of anaesthetic drugs to provide smooth onset and short, predictable drug offset is now feasible. This may be advantageous in the context of a cost conscious health service moving towards ever shorter inpatient stay and more patients treated as day cases. 90004 90002 The increasing popularity of TIVA is testament to its ease of use and perceived benefits and for the modern anaesthetist it represents a new branch of the speciality with major advantages. 90004 90002 90004 90002 90004 90002 90046 Sources: 90047 90048 http: // www.sivauk.org/welcome.php 90048 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1390758 90048 http://www.nature.com/npp/journal/v29/n3/full/1300364a. html 90048 http://www.rila.co.uk/issues/full/download/51c2200970f1a38a5988b71b12d9f52f407682.pdf 90048 http://bja.oxfordjournals.org/cgi/reprint/86/4/523.pdf 90004 90002 90004 90002 John Sandham 90046 IEng MIET MIHEEM 90047 90004 90002 90004 90002 90004.90000 General Anesthetics: Inhaled and Intravenous Anesthetics 90001 90002 90003 90004 Anesthesiology 90005 CONTINUE LEARNING START NOW CONTINUE LEARNING START NOW 90006 CATEGORIES 90007 90008 90009 The Lecturio Medical Online Library 90010 90009 Pre-Med Curriculum 90008 90009 Biology 90010 90009 Chemistry 90010 90009 Physics 90010 90009 Statistics 90010 90021 90010 90009 Preclinical Curriculum 90008 90009 Anatomy 90010 90009 Behavioral Science 90010 90009 Biochemistry 90010 90009 Biomedical Sciences 90010 90009 Embryology 90010 90009 Epidemiology & Biostatistics 90010 90009 Histology 90010 90009 Immunology 90010 90009 Microbiology 90010 90009 Pathology 90010 90009 Pharmacology 90010 90009 Physiology 90010 90021 90010 90009 Clinical Curriculum 90008 90009 Anesthesiology 90010 90009 Cardiology 90010 90009 Dermatology 90010 90009 Emergency Medicine 90010 90009 Endocrinology 90010 90009 Family Medicine 90010 90009 Gastroenterology 90010 90009 Gynecology 90010 90009 Hematology 90010 90009 Hepatology 90010 90009 Infectious Diseases 90010 90009 Medical Genetics 90010 90009 Neurology 90010 90009 Ophthalmology 90010 90009 Otolaryngology (ENT) 90010 90009 Oncology 90010 90009 Orthopedics 90010 90009 Psychiatry 90010 90009 Pediatrics 90010 90091 90021 90010 90021.90000 SMOOTH EMERGENCE FROM GENERAL ANESTHESIA 90001 90002 Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California. 90003 email rjnov @ yahoo.com 90003 phone 650-465-5997 90005 Latest posts by the anesthesia consultant (see all) 90002 Anesthesiologists prefer their patients to have a gentle transition from the anesthetized state into the awake state. The desired goal is «smooth emergence.» When the general anesthetic requires an endotracheal tube, an issue is how to awaken the patient with minimal patient coughing and bucking while the tube remains in the trachea. Coughing and bucking are associated with increases in blood pressure and heart rate, as well as increased intrathoracic pressure, intracranial pressure, intraocular pressure, and increased bleeding or edema in head and neck surgeries.90005 90002 90005 90002 An anesthesia colleague wrote to me several months ago, asking for my recommendations for achieving smooth emergence. His question prompted me to write this column. 90005 90002 In a previous column I opined on the virtues of awake extubation rather than deep extubation. I remain convinced that awake extubation is the preferred and safest practice for almost every patient. What can we do to reduce the agitation, coughing, bucking, hypertension, and tachycardia that can occur with awake extubation? 90005 90002 I’ve performed countless general anesthetics for surgeries requiring smooth emergence, specifically carotid endarterectomies, rhinoplasties, facelifts, craniotomies, thyroidectomies, and other head and neck procedures.In each of these surgeries, the surgeon has an intense interest in a gentle anesthesia wake-up, free of coughing, bucking, or hypertension. 90005 90002 90017 Miller’s Anesthesia 90018 (2015, Eighth edition, Chapter 70, 2158-99) discusses this topic in the chapter «Anesthesia for Neurologic Surgery,» written by lead author John C. Drummond. The chapter states the following: 90005 90020 90021 «There is a paucity of systematically obtained clinical data to give a perspective to the actual magnitude of the risks associated with emergences that are not considered smooth.»90022 90021 «We encourage trainees to include in their anesthetic technique as much narcotic as is consistent with spontaneous ventilation at the conclusion of the procedure.» 90022 90021 «We also have the bias that patients emerge more rapidly and smoothly when the last inhaled anesthetic to be withdrawn is nitrous oxide and that clinicians should seek to avoid the ‘neither here nor there’ phase of anesthesia that occurs in patients who are stimulated in the face of residual exhaled concentrations of volatile anesthetic on the order of 0.2 to 0.3 MAC. » 90022 90021 «A common practice among neuroanesthetists near the conclusion of a craniotomy is the relatively early discontinuation of the volatile anesthetic with supplementation, if necessary, of residual nitrous oxide with propofol by either bolus increments or infusion at rates in the range of 12.5 to 25 μg / kg / hr. » 90022 90021 «We commonly administer 1.5 mg / kg of intravenous lidocaine just before the head movement associated with applying the dressing.» 90022 90021 «Because of the premium placed on minimizing coughing and straining and hypertension, there may be a temptation to extubate from the trachea before complete recovery of consciousness.This may be acceptable in some circumstances. However, it should be undertaken with caution. . . it would, in general, be best to wait until the likelihood of the patient’s recovery of consciousness is confirmed or until patient cooperation and airway reflexes are likely to have recovered. » 90022 90033 90002 I’d make the following observations to adapt these recommendations to non-neurosurgical patients: 90005 90020 90021 It’s true there’s a paucity of data on the «best» way to achieve smooth emergence.Multiple papers have been published, each studying a small series of patients and examining a different regimen for emergence. The number of patients in these series is small, and none of the papers are linked to improved outcomes. 90022 90021 Regarding the appropriate amount of narcotic, I recommend dosing the narcotic as required to treat post-operative pain, and no more. In certain surgeries such as a rhinoplasty or a facelift, the surgeon will inject local anesthetic to blunt the bulk of postoperative pain.Additional intravenous narcotic may decrease the stimulus of an endotracheal tube in situ, but the extra narcotic doses come with the risk of increased narcotic side effects, i.e. nausea and sedation. 90022 90021 Contrary to the recommendations in 90017 Miller’s Anesthesia 90018, my practice for years has been to discontinue nitrous oxide first, and to continue a low inspired concentration of 1% sevoflurane in 100% oxygen for the last five minutes of general anesthetics. I’ve found it effective for smooth emergence, following the additional suggestions listed and numbered in the second half of this column below.In addition, the 100% oxygen supplies an extra margin of safety prior to extubation. 90022 90033 90002 Based on 32 years of practice and over 25,000 personally administered anesthetics, these are my suggestions to maximize the smooth emergence of intubated patients: 90005 90020 90021 Utilize the «no touch» extubation technique as described by Tsui in 90017 Anesthesia and Analgesia 90018 in 2004. At the conclusion of adenotonsillectomy in children, once volatile anesthetics were discontinued, no further stimulation was applied to the patients, i.e. no suctioning, or repositioning. No laryngospasm, oxygen desaturation, or severe coughing occurred in any patient. Sheta also reported on this «no touch» technique in a prospective, randomized, single-blinded, comparative study. Sixty adult nasal or sinus surgery patients were randomized to standard awake intubation technique vs. a «no touch» extubation technique. There was no laryngospasm among patients who were extubated with the «no touch» technique. The control group had a higher statistical incidence in the number and severity of desaturation episodes, incidence of non-purposeful movement, biting, and hoarseness (90017 P 90018 <0.05). Significant oozing from the wound was less in the "no touch" group. (90017 P 90018 <0.05). Hemodynamic responses (tachycardia or hypertension) prior to extubation were significantly less in the "no touch" group (90017 P 90018 <0.05). 90022 90021 Utilize intratracheal lidocaine (e.g. 4 cc of 4% lidocaine) at the time of intubation. Minogue showed that intratracheal lidocaine decreased coughing on emergence for anesthetics <2 hours in duration. 90022 90021 If the patient begins to wake earlier than desired, administer 50 mg increments of propofol for the typical 70 kg adult patient, to deepen anesthetic depth temporarily as needed.90022 90021 If the patient develops hypertension or tachycardia prior to extubation, administer 5-10 mg increments of labetolol IV as needed. 90022 90021 Your primary value regarding extubation must be safety. While a patient's coughing or bucking may displease the surgeon, your clinical practice of anesthesia must be based on the maintenance of Airway-Breathing-Circulation. Waiting until your patient is awake enough to maintain their own airway safely is more important than trying to keep the surgeon happy because he or she does not like to see any bucking.90022 90033 90002 Data exists to support the use of dexmedotomidine or remifentanil to smooth emergence. Because of the expense of these medications, neither is part of my routine extubation protocol. Representative studies on these two drugs include: 90005 90070 90021 Dexmedotomidine: Lee JS, et al, studied adults undergoing elective thyroidectomy under sevoflurane anesthesia. Patients were randomized to receive either dexmedetomidine 0.5 μg / kg IV (Group D, n = 70) or saline (Group S, n = 71), each combined with a low-dose remifentanil infusion ten minutes before the end of surgery.Results showed the addition of this single dose (0.5 μg / kg) of dexmedetomidine duringemergence from sevoflurane-remifentanil anesthesia was effective in attenuating coughing and hemodynamic changes, and did not exacerbate respiratory depression. 90022 90073 90070 90021 Remifentanil: Lee JH, et al, studied seventy female patients undergoing thyroidectomy under general anesthesia using sevoflurane and remifentanil. Patients were randomly assigned to IV lidocaine (Group L, n = 35) or remifentanil (Group R, n = 35).In Group L, at the end of surgery both the sevoflurane and the remifentanil infusion were stopped, and lidocaine 5 mg / ml was administered IV. In Group R, the remifentanil infusion was continued until extubation. The incidence of cough during the emergence was significantly higher in the lidocaine group than in the remifentanil group (72.7% vs. 20.6%, P <0.001), and so was the grade of cough (P <0.001). The authors concluded that an infusion of remifentanil reduced responsiveness to the tracheal tube during emergence from general anesthesia more effectively than IV lidocaine in female patients undergoing thyroid surgery.90022 90073 90002 A recent study by Nath et al. showed a decrease in emergence coughing with by preloading of endotracheal tube cuffs with alkalinized lidocaine. Two hundred patients were randomly assigned to alkalinized lidocaine (2 ml 2% lidocaine + 8 ml of 8.4% sodium bicarbonate) or 10 ml of saline prefilled into the endotracheal tube cuff 90 minutes prior to intubation. Results showed a significantly decreased incidence of coughing on emergence in the lidocaine group. In addition, the study showed the incidence of coughing was inversely related to the amount of narcotic used in the anesthetic, i.e. more narcotic -> less emergence coughing. 90005 90002 Anesthesia practice is both an evidence-based science and an experienced-based art. There will be multiple recipes for smooth emergence. You may choose the advice from 90017 Miller’s Anesthesia 90018, you may choose my recommendations from theanesthesiaconsultant.com, or you may choose an entirely different method that includes dexmedotomidine or remifentanil. 90005 90002 May all your patients emerge safely and smoothly. 90005 90002 May you, in the words of the Sade song, be a «Smooth Operator.»90005 90002 90005 90002 90091 The most popular posts for laypeople on The Anesthesia Consultant include: 90092 90005 90002 How Long Will It Take To Wake Up From General Anesthesia? 90005 90002 Why Did Take Me So Long To Wake From General Anesthesia? 90005 90002 Will I Have a Breathing Tube During Anesthesia? 90005 90002 What Are the Common Anesthesia Medications? 90005 90002 How Safe is Anesthesia in the 21st Century? 90005 90002 Will I Be Nauseated After General Anesthesia? 90005 90002 What Are the Anesthesia Risks For Children? 90005 90002 90005 90002 90091 The most popular posts for anesthesia professionals on The Anesthesia Consultant include: 90092 90005 90002 10 Trends for the Future of Anesthesia 90005 90002 Should You Cancel Anesthesia for a Potassium Level of 3.6? 90005 90002 12 Important Things to Know as You Near the End of Your Anesthesia Training 90005 90002 Should You Cancel Surgery For a Blood Pressure = 178/108? 90005 90002 Advice For Passing the Anesthesia Oral Board Exams 90005 90002 What Personal Characteristics are Necessary to Become a Successful Anesthesiologist? 90005 90002 90005 90002 * 90003 * 90003 * 90003 * 90005 90002 Published in September 2017: The second edition of 90017 THE DOCTOR AND MR. DYLAN 90018, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.90005 90002 90091 KIRKUS REVIEW 90092 90005 90002 In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son. 90005 90002 Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota.The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother / daughter pair of Lena and Echo Johnson.However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: «Are you my husband, Nico? Or my dependent? » The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when «dark blood percolated» from a patient’s nostrils «like coffee grounds.»Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught «every singer with a less-than-perfect voice … how to sneer and twist off syllables.» Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches. 90005 90002 Nuanced characterization and crafty details help this debut soar. 90005 90002 Click on the image below to reach the Amazon link to 90017 The Doctor and Mr.Dylan 90018: 90005 90002 90005 90002 90154 90091 LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW: 90092 90157 90005 90002 90005 90002 90091 90092 90005 90002 90005 90154 Like this: 90157 90002 Like Loading … 90005 90002 90154 90017 Related 90018 90157 90005.90000 HOW TO WAKE UP PATIENTS PROMPTLY FOLLOWING GENERAL ANESTHETICS 90001 90002 Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.90003 email [email protected] 90003 phone 650-465-5997 90005 Latest posts by the anesthesia consultant (see all) 90002 Two patients arrive simultaneously in the recovery room following general endotracheal anesthetics. One patient is unresponsive and requires an oral airway to maintain adequate respiration. In the next bed, the second patient is awake, comfortable and conversant. How can this be? It occurs because different anesthetists practice differently. Some can wake up patients promptly, and some can not.90005 90002 90005 90002 90005 90002 Does it matter if a patient wakes up promptly after general anesthesia? It does. An awake, alert patient will have minimal airway or breathing problems. When it’s time to walk away from your patient in the recovery room, you’ll worry less if your patient is already talking to you and has minimal residual effects of general anesthesia. Whether the surgery was a radical neck dissection, a carotid endarterectomy, a laparotomy, or a facelift, it’s preferable to have your patient as awake as possible in the recovery room.90005 90002 What can you do to assure your patients wake up promptly? A Pubmed search will give you little guidance. There’s a paucity of data or evidence in the medical literature on how to wake patients faster. You’ll find data on ultra-short acting drugs such as propofol and remifentanil. This data helps, but the skill of waking up a patient on demand is more an art than a science. Textbooks give you little advice. 90015 Anesthesiologist’s Manual of Surgical Procedures 90016, (4 90017 th 90018 Edition, 2009), edited by Jaffe and Samuels, has an Appendix that lists Standard Adult Anesthetic Protocols, but there is little specific information on how to titrate the drugs to ensure a timely wakeup.90005 90002 Based on 29 years of administering over 20,000 anesthetics, this is my advice on how to wake patients promptly from general anesthesia: 90005 90022 90023 Propofol. Use propofol for induction of anesthesia. You may or may not choose to infuse propofol during maintenance anesthesia (e.g. at a rate of 50 mcg / kg / min) but if you do, I recommend turning off the infusion at least 10 minutes before planned wakeup. This allows adequate time for the drug to redistribute and for serum propofol levels to decrease enough to avoid residual sleepiness.90024 90023 Sevoflurane. Sevoflurane is relatively insoluble and its effects wear off quickly when the drug is ventilated out of the lungs at the conclusion of surgery. I recommend a maintenance concentration of 1.5% inspired sevoflurane in most patients. I drop this concentration to 1% while the surgeon is applying the dressings. When the dressings are finished, I turn off the sevoflurane and continue ventilation to pump the sevoflurane out of the patient’s lungs and bloodstream. The expired concentration will usually drop to 0.2% within 5-10 minutes, a level at which most patients will open their eyes. 90024 90023 Nitrous oxide. Unless there is a contraindication (e.g. laparoscopy or thoractomy) I recommend you use 50% nitrous oxide. It’s relatively insoluble, and adding nitrous oxide will permit you to utilize less sevoflurane. I recommend turning off nitrous oxide when the surgeon is applying the dressings at the end of the case, and turning the oxygen flow rate up to 10 liters / minute while maintaining ventilation to wash out the remaining nitrous oxide.90024 90023 Narcotics. Use narcotics sparingly and wisely. I see overzealous use of narcotics as a problem. Prior to inserting an endotracheal tube, it’s reasonable to administer 50 — 100 mcg of fentanyl to a healthy adult or 0 -50 mcg of fentanyl to a geriatric patient. A small dose serves to blunt the hemodynamic responses of tachycardia or hypertension associated with larynogoscopy and intubation. Bolusing 250 mcg of fentanyl prior to intubation is an unnecessary overdose. The use of ongoing doses of narcotics during an anesthetic depends on the amount of surgical stimulation and the anticipated amount of post-operative pain.You may administer intermittent increments of narcotic (I may give a 50-100 mcg dose of fentanyl every hour) but I recommend your final narcotic bolus be given no less than 30 minutes prior to the anticipated wakeup. Undesired high levels of narcotic at the conclusion of surgery contribute to oversedation and slow awakening. If your patient complains of pain at wakeup, further narcotic is titrated intravenously to control the pain. Your patient’s verbal responses are your best monitor regarding how much narcotic is needed.Your goal at wakeup should be to have adequate narcotic levels and effect, but no more narcotic than needed. 90024 90023 Intra-tracheal lidocaine. I recommend spraying 4 ml of 4% lidocaine into the larynx and trachea at laryngoscopy prior to inserting the endotracheal tube. I can not cite you any data, but it’s my impression that patients demonstrate less bucking on endotracheal tubes at awakening when lidocaine was sprayed into their tracheas. Less bucking enables you to decrease anesthetic levels further while the endotracheal tube is still in situ.90024 90023 Local anesthetics. Local anesthetics are your friends at the conclusion of surgery. If the surgeon is able to blunt post-operative pain with local anesthesia or if you are able to blunt post-operative pain with a neuroaxial block or a regional block, your patient will require zero or minimal intravenous narcotics, and your patient will wake up more quickly. 90024 90023 Muscle relaxants. Use muscle relaxants sparingly. Nothing will slow a wakeup more than a patient in whom you can not reverse the paralysis with a standard dose of neostigmine.This necessitates a delay in extubation until muscle strength returns. Muscle relaxation is necessary when you choose to insert an endotracheal tube at the beginning of an anesthetic, but many cases do not require paralysis for the duration of the surgery. When you must administer muscle relaxation throughout surgery, use a nerve stimulator and be careful not to abolish all twitch responses. Avoid long-acting paralyzing drugs such as pancuronium, as you will have difficulty reversing the paralysis if surgery concludes soon after you’ve administered a dose.Use rocuronium instead. Avoid administering a dose of rocuronium if you believe the surgery will conclude within the next 30 minutes-it may be difficult to reverse the paralysis, and this will delay wakeup. 90024 90023 Laryngeal Mask Airway (LMA). When possible, substitute an LMA for an endotracheal tube. Wakeups will be smoother, muscle relaxants are unnecessary, and narcotic doses can be titrated with the aim of keeping the patient’s spontaneous respiratory rate between 15- 20 breaths per minute.90024 90023 Temperature monitoring and forced air warming. Cold is an anesthetic. Strive to keep your patient normothermic by using forced air warming. If your patient’s core temperature is low, wakeup will be delayed. 90024 90041 90002 10. Consider remaining in the operating room after surgery until your patient is awake enough to respond to verbal commands. This is my practice, and I recommend it for safety reasons. In the operating room you have all your airway equipment, drugs, and suction at your fingertips.If an unexpected emergence event occurs, you’re prepared. If an unexpected emergence event occurs in an obtunded patient in the recovery room, your resuscitation equipment will not be as readily available. If your patient is responsive to verbal commands in the operating room, your patient will be wakeful on arrival in the recovery room. 90005 90002 Is this protocol a recipe? Yes, it is. You’ll have your own recipe, and your ingredients may vary from mine. You may choose to administer desflurane instead of sevoflurane.You may choose sufentanil, morphine, or meperidine instead of fentanyl. My advice still applies. Use as little narcotic as is necessary, and try not to administer intravenous narcotic during the last 30 minutes of surgery. If you use a remifentanil infusion, taper the infusion off early enough so the patient is wakeful at the conclusion of surgery. 90005 90002 The principles I’ve recommended here are time-tested and practical. Follow these guidelines and you’ll experience two heartwarming scenarios from time to time: 1) Patients in the recovery room will ask you, «You mean the surgery is done already? I can not believe it, «and 2) Recovery room nurses will ask you,» Did this patient really have a general anesthetic? She’s so awake! » 90005 90002 Your chest will swell with pride, and you’ll feel like an artist.Good luck. 90005 90002 90005 90002 90015 90016 90005 90002 90057 The most popular posts for laypeople on The Anesthesia Consultant include: 90058 90005 90002 How Long Will It Take To Wake Up From General Anesthesia? 90005 90002 Why Did Take Me So Long To Wake From General Anesthesia? 90005 90002 Will I Have a Breathing Tube During Anesthesia? 90005 90002 What Are the Common Anesthesia Medications? 90005 90002 How Safe is Anesthesia in the 21st Century? 90005 90002 Will I Be Nauseated After General Anesthesia? 90005 90002 What Are the Anesthesia Risks For Children? 90005 90002 90005 90002 90057 The most popular posts for anesthesia professionals on The Anesthesia Consultant include: 90058 90005 90002 10 Trends for the Future of Anesthesia 90005 90002 Should You Cancel Anesthesia for a Potassium Level of 3.6? 90005 90002 12 Important Things to Know as You Near the End of Your Anesthesia Training 90005 90002 Should You Cancel Surgery For a Blood Pressure = 178/108? 90005 90002 Advice For Passing the Anesthesia Oral Board Exams 90005 90002 What Personal Characteristics are Necessary to Become a Successful Anesthesiologist? 90005 90002 90005 90002 90005 90002 90005 90002 90005 90002 * 90003 * 90003 * 90003 * 90005 90002 Published in September 2017: The second edition of 90106 THE DOCTOR AND MR.DYLAN 90107, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan. 90005 90002 90057 KIRKUS REVIEW 90058 90005 90002 In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son. 90005 90002 Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money.Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door.As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother / daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: «Are you my husband, Nico? Or my dependent? » The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when «dark blood percolated» from a patient’s nostrils «like coffee grounds.»Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught «every singer with a less-than-perfect voice … how to sneer and twist off syllables.» Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches. 90005 90002 Nuanced characterization and crafty details help this debut soar. 90005 90002 Click on the image below to reach the Amazon link to 90106 The Doctor and Mr.Dylan 90107: 90005 90002 90005 90002 90005 90002 90128 90057 LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW: 90058 90131 90005 90002 90005 90002 90057 90058 90005 90002 90005 90128 Like this: 90131 90002 Like Loading … 90005 90002 90128 90106 Related 90107 90131 90005.