Colonoscopy without sedation. Possible..but does it miss the point?

January 18, 2009

Colonoscopy, repeated at 5-10 year intervals, is recommended to detect colon cancer after age 50. As the American (and global) population ages, more colonoscopies will be performed, and more colonoscopists are needed.

One controversy is – who is qualified to perform a colonoscopy? Family physicians with special training argue that they are, and this would certainly ease the pressure on gastroenterologists (or offer a competitive threat?).

Another contentious area is – who is qualified to provide the sedation that most patients expect? Some gastroenterologists say that sedation is so safe that they can provide, or at least supervise it, while they do the colonoscopy. Anesthesiologists would argue the contrary. (Disclaimer: I am one – an anesthesiologist).

Outside the United States, colonoscopy is often done without sedation. This may even be the norm, as discussed in an American Medical News article which reports on a center in California which has been doing these on a routine basis, in volunteers, with some success (78% completed the study without drugs).

It’s clear from this article that colonoscopy without sedation is possible in America. But that is hardly a surprise. What’s missing in this analysis, and all the controversy, is outcomes. Not the number of colonoscopies completed, which is what is reported in these studies, but how many lesions were picked up (or missed) during the colonoscopy. That’s a much more difficult study to do, but isn’t finding (or ruling out) cancer the reason for undergoing this rather unpleasant test?

Intuitively, an endoscopist who does not have the additional responsibility of sedation, or the time pressure of completing the study as quickly as possible in an unsedated patient, has better conditions to fulfill his primary role – to find cancerous or pre-cancerous lesions in the colon and rectum. But that’s just my suspicion – let’s hope the outcome studies get done.


Blood clots after surgery – call to action

September 26, 2008

Deep vein thrombosis (DVT) and pulmonary embolism (PE) – “blood clots” – kill about 100,000 Americans each year. Many blood clots occur after routine elective surgery – especially spine surgery and major surgery on the hip or knee.

An excellent consumer guide to the risks, prevention and treatment of blood clots can be found here.

The Office of the Surgeon General in the US recently called for action to address this major public health problem. The Surgeon General’s Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism documents the problems DVT and PE pose, as well as strategies to reduce the risk of developing the conditions. Clearly we need to improve public knowledge about risk factors, triggering events, and symptoms of the disease, which is often silent.

Before any surgical procedure, particularly those requiring more than a day or so in hospital, you should be evaluated for any risk factors for a blood clot. People at risk need preventive measures, which can include anticoagulants, like heparin, special stockings, or the use of automated calf compression devices.

Rapid mobilisation – i.e. getting out of bed – is one of the best ways to avoid blood clots and is one of the reasons why patients having outpatient or day surgery very seldom need specific preventive treatments. Read the rest of this entry »

Avoiding harm from the drugs you take

September 24, 2008

Ten Eight Rules for Safe Drug Use

Before surgery the medications you take should be listed accurately and in detail – their names, doses, and the times at which you take them. Medications that you purchase without a prescription may be as important as those prescribed by your doctor.

Why is a medication history important before surgery? Read the rest of this entry »

“I could not breathe in the recovery room”

February 17, 2008

What could be more frightening that being awake but paralysed and unable to breathe? No, I’m not talking about “Awake”, the scientifically inaccurate recent movie that dramatizes the rare but distressing experience of being awake in the middle of surgery. Rather, I am referring to the equally upsetting events that sometimes occur during recovery from general anesthesia.

Here is a vivid description, sent to a forum on the excellent consumer health site NetWellness, where I field questions about anesthesia:

“I have just had my ovaries and tubes removed because of my family history. When I woke in the recovery room, I had the most terrible experience of my life. My eyes were open, but I could not move or breath. No air would go in or out, I could not raise my arms in distress or do anything to raise the alarm that I could not breath, only stare into the eyes of the nurse. I thought, any minute now I am going to die, It was so distressing, I have been having flash backs ever since.” Read the rest of this entry »

Ask-Advise-Refer to Stop Smoking Before Surgery

February 1, 2008

The American Society of Anesthesiologists has a new campaign to help patients stop smoking at the time of surgery. It’s called Ask-Advise-Refer. All patients should be asked if they smoke, even if the answer is known, to demonstrate that smoking is significant. All patients should be advised to stop smoking before surgery and stay off cigarettes until at least one week after surgery. Patients should be referred for smoking cessation. There is a national Tobacco Quitline number (1-800-QUIT-NOW) which provides free counseling. The ASA web-site provides access to additional resources, including information regarding reimbursement for providing tobacco interventions.

How to Avoid (One Type of) Hospital Infection

January 24, 2008

Peter Pronovost is a different kind of medical hero. An anesthesiologist who is making an impact on hospital care far greater than almost any new pharmaceutical or high-tech surgical technique.

Implementation of Pronovost’s simple checklist for prevention of catheter-related bloodstream infection – the infection that can arise from intravenous lines inserted into the central circulation – has resulted in a dramatic reduction in these infections in a large group of Michigan hospitals. In many hospitals, the incidence, quite astonishingly, dropped to ZERO, sustained over a period of months.

Read the rest of this entry »

Does anesthesia cause sleep disturbance?

January 11, 2008

Sleep disturbance after major surgery is common, and some people assume anesthesia is the cause. That is probably wrong.

The “surgical stress response“, the body’s hormonal and metabolic response to the trauma of surgery, is quite profound and has an important effect on the subsequent amount and quality of sleep. The bigger the surgery, it seems, the more significant is the stress response and the accompanying sleep disturbance.

Sleep During the stress response, hormones from the pituitary gland are released, and the sympathetic nervous system is activated (adrenaline and its companion “fight or flight” hormones). Metabolic changes include increased blood sugar, and breakdown of body protein. Injured tissues release cytokines and other potent chemicals associated with inflammation.

Pain, and the medications used to treat pain, sedatives, food deprivation, fever, psychological factors, age, and a person’s usual sleep profile all affect sleep after surgery.

Read the rest of this entry »

Help Avoid Mistakes in Your Surgery

January 7, 2008


In 2002 the Joint Commission initiated a campaign to improve patient safety called SpeakUp. Many of the materials produced and distributed are copyright free. Here I reproduce a brochure titled “Help Avoid Mistakes in Your Surgery”. I highly recommend that anyone about to undergo surgery read, and take action on, these suggestions. You can download the brochure (free) here.

Preparing for your surgery

Read the rest of this entry »

Welcome to the SurgiPrep Blog

December 11, 2007

I’m an anesthesiologist. About 8 years ago I started answering questions about anesthesia on an excellent and popular consumer health website called NetWellness. NetWellness is linked to Case Western Reserve University, where I am a faculty member. Answering over 350 questions, most of which can be found on SurgiPrep, my site dedicated to preoperative evaluation, or in their original form on NetWellness, has taught me a lot.

I’ve learned that many people are more worried about anesthesia than they are about their surgery. It’s particularly anxiety provoking when a loved one – a child say, or a parent, is about to “go under”. It’s also a huge concern when things don’t turn out the way people expect. Sometimes, complications, like a breathing problem, a nerve injury, or an allergic reaction, are clearly attributable to the drugs or techniques that are part of anesthesia. People want these problems explained and they want to know how to avoid them in the future.

I’ve discovered to my surprise and fascination that some people will attribute almost any new symptom to a recent anesthetic (examples: curly hair, loss of hair, oily skin, decreased energy, increased energy, bad dreams, bad breath, loss of taste, loss of concentration). Either we anesthesiologists are missing some weird and possibly important stuff happening right beneath our face masks, or we’re not doing a good job of informing and listening to our patients. (It’s probably some of both).

I’ve heard from people angry with the way they’ve been treated by their doctors. Often all they’ve wanted is a bit of time and a simple explanation from their doctors. Problem is, time is a commodity most medical practitioners are short of. I’ve taken time to explain how anesthesia works, how it’s administered, and by whom, what the choices are (when choices exist), and what outcomes, good or bad, can be expected, in the simplest terms possible. (This is despite the reality that general anesthesia, like consciousness itself, is a rather mysterious process and the science underlying it is still being explored).

Why do I care to do this? Most anesthesiologists don’t go into their field because they like to chat, but during my earlier professional career I was forced to do a lot of it – first during a 6 month stint as a psychiatry house officer (in Harare, Zimbabwe!) and later as a family physician (in Saskatchewan, Canada). I recognized the power of talk, as an expression of caring and a mechanism of healing. Perhaps something rubbed off. I am not the most garrulous individual (pardon the pun) but I do like to write and I enjoy trying to make scientific and medical concepts more understandable.

In this blog I hope to explore, in a little more depth, some of the issues, weird and commonplace, expected and unexpected, that my NetWellness correspondents have brought to light. This blog does not replace an interview with your friendly local anesthesiologist, or surgeon, but reading the articles I post here may help you to have an informed conversation with your doctors when its your time to undergo a medical or surgical procedure requiring anesthesia.

Please join me on this journey.

Gary Kantor, MD