Alcohol + anesthesia + surgery: not a good mix?

September 8, 2008

8.3% of Americans have a drinking disorder. Europeans drink even more, and alcohol is the third highest risk factor for death and disability in the general population.

The August 2008 edition of Anesthesiology reports that in a German preoperative clinic, 6.9% of patients were determined by an anesthesiologist to have an alcohol use disorder.  That would seem to be in keeping with the population studies cited above, but a 10-question computerized identification test identified more than twice as many patients – 18.1% – as problem drinkers. Those Berliners really know how to party!

This is actually not surprising. Computerized assessments of alcohol consumption have been used as far back as 1977.  Forty years of study have shown that computers do a better job than people in detecting these kinds of problems reliably and at low cost.  People are actually more likely to disclose problems of a personal nature, including mental health issues, to a computer than to your average medical interviewer.

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Does Brain Monitoring Prevent Anesthesia Awareness?

June 1, 2008

Studies suggest that one or two people in every thousand who undergo general anesthesia experience awareness during the procedure, maybe more in children. The Joint Commission, which inspects hospitals in the US, has made awareness during general anesthesia a “sentinel event.” (If you’re a hospital, a practitioner, or a patient, you definitely want to avoid these). The movie “Awake” and various TV programs have dramatized the issue of awareness.

The victims of awareness tell us the experience can be excruciating. Fortunately, most individuals do not experience physical pain but there is the possibility of later developing debilitating post-traumatic stress disorder. (A study of seven children confirmed to have had awareness found none of them had PTSD or any other troubling psychological problems a year later. This does not establish that PTSD does not occur in children who have had awareness but does suggest that long term problems, at least in children, are far from inevitable).

Can awareness be prevented with brain monitoring technology? An important new NEJM study looks at this.

EEG image (Wikipedia commons) Read the rest of this entry »

Sedation for colonoscopy – do it yourself

February 4, 2008

Adults over age 50 should be screened for colon cancer. Although “virtual colonoscopy” is an appealing alternative, a “real” colonoscopy is still the gold standard. This involves a large black hosepipe-sized endoscope being inserted where the sun never shines, so its perhaps not surprising that colon cancer screening rates aren’t what they should be.

In most cases, colonoscopy isn’t extremely painful but it is uncomfortable and certainly not much fun; most patients in the United States receive some form of sedation for it. There is lots of controversy over who provides this sedation and what is given. A form of self-administered sedation creates new options. Read the rest of this entry »

Isoflurane anesthesia is bad for demented rats

February 3, 2008

We know that about 20% of elderly patients have Postoperative Cognitive Dysfunction (POCD) after surgery but we still don’t know what the link, if any, is to general anesthesia. This February 2008 study in the journal Anesthesia & Analgesia provides laboratory evidence that anesthesia might hasten the onset of Alzheimer’s in genetically susceptible patients.

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Why hasn’t dad woken up after his heart surgery?

January 26, 2008

Sedation helps patients tolerate the uncomfortable bodily invasions of high tech intensive care. But when dad isn’t “waking up”, or just “isn’t himself”, many family members want to know whether sedatives are responsible for the prolonged problems with wakefulness, memory, and cognition seen in a significant number of patients who have received care in the Intensive Care Unit (ICU).

Benzodiazepines like lorazepam (Ativan)(cousin:Valium) are inexpensive, effective and safe sedatives for this purpose, with very little impact on organ systems other than the brain (that’s a good thing).Flowers

Dexmedetomidine is a new sedative drug marketed as the more easily pronounceable Precedex™. It is cousin to clonidine, a blood pressure medicine that’s been around for many years, which also has sedative properties. Precedex has pain-relieving properties and can cause the heart to slow and the blood pressure to drop in some patients.

Because Precedex works in a different way to the standard sedatives (it blocks alpha-adrenergic receptors) there is hope that it represents a better option for some conditions and procedures. Could it have less long term effect than other drugs on the brain?

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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.

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Surgery – A Good Time to Quit Smoking

January 17, 2008

Quitting smoking is just about the best thing anyone can do for their health.

Are there any benefits to smoking, now that it no longer has much sex appeal, and the French have even banned it in the cafes of the Champs Elysees? The only medical benefit of smoking I know of is a reduction in the risk of postoperative nausea and vomiting (PONV). The cause is not certain, but numerous studies have shown this to be true. Although PONV isn’t much fun this is not, I hasten to add, a good reason to take up the noxious weed before your next operation.

No SmokingSmoking creates added risk for people having surgery and anesthesia. For instance, smoking increases your risk of respiratory complications, and your risk of wound infection.

The perioperative period (before and immediately after surgery) creates forced abstinence – try lighting up in the surgical ward these days and you will pretty soon find yourself surrounded by irate nurses, fellow patients and possibly the security staff. So surgery represents a perfect opportunity to quit.

A new meta-analysis (study of studies) in the Canadian Journal of Anesthesia confirms that the preoperative setting represents a “teachable moment”. Read the rest of this entry »

Video games treat pain

January 2, 2008

Immersive virtual reality (VR)

Pain has been declared the “fifth vital sign”, signifying its importance to patients and health care providers. A common therapeutic goal in American hospitals is to ensure that patients have a pain score of 4 or less (out of ten) after surgery .

Unfortunately, all pharmaceutical pain treatments have potential side-effects. The aggressive treatment of postoperative pain with standard pain killers may lead to a range of complications, including gastro-intestinal side-effects (nausea, vomiting, constipation), over-sedation, hematological problems (bleeding or thrombosis), and even death from respiratory depression. Non-pharmacological approaches to the treatment of pain, such as hypnotherapy, acupuncture and music, are therefore an attractive option.

A recent study of immersive Virtual Reality (VR) published in the journal Anesthesia & Analgesia (Dec 2007) adds to the evidence that this technology can be useful in the treatment of pain.

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Does anesthesia “fry” the elderly brain?

December 30, 2007

One of the most common fears of people undergoing anesthesia and surgery is that anesthesia will cause harm, even permanent damage, to the brain. The traditional view is that anesthetic agents are rapidly metabolized (broken down) and/or excreted from the body, their effects are readily reversed, and anesthesia is therefore unlikely in the long run to cause neurologic injury.

We know that anesthetic agents affect many aspects of brain physiology, altering blood supply to the brain, metabolism, neurotransmitters, cerebrospinal fluid production, and more. These effects are being investigated in the laboratory and through the use of special imaging techniques. The picture that emerges is as complex as the brain itself, and is sometimes surprising. For instance, certain anesthetic agents seem to protect, not injure, the brain – at least in animal experiments.

Your Brain on Drugs

More than 50 years ago, it was reported that some older people have brain problems after surgery, and recent research challenges the belief that a well-conducted anesthetic and complication-free surgical procedure is totally neurologically benign.

The term postoperative cognitive dysfunction (POCD) has been coined to describe the mental changes, (in the areas of thinking, attention and memory) that do occur in some patients after anesthesia and surgery.

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“Shock treatment” reduces postoperative nausea and vomiting

December 30, 2007

Nausea and vomiting after anesthesia, known as PONV (postoperative nausea and vomiting) is still common, despite new anesthetic agents and anti-nausea medications tested in hundreds of clinical studies. Acupuncture, and related techniques that use pressure (acupressure) or electrical pulses (transcutaneous electrical nerve stimulation) instead of needles, are fairly well studied in the prevention of PONV. These prevention measures seem to be as effective as the standard drugs. There are commercial bracelet devices that exploit this effect. The standard acupuncture point is called Nei guan, or P6, and is located on the inside of the wrist, between two tendons. These systems also appear to be effective in the prevention of motion sickness.

Neuromuscular blocking agents, also known as muscle relaxants (they are in fact reversible, paralyzing drugs), are used routinely in anesthesia for certain surgical procedures. The effect of these drugs is monitored with nerve stimulators, portable devices that deliver small electrical pulses via adhesive electrode patches applied to the skin. As the paralysis wears off, muscles supplied by the nerve that is stimulated begin to twitch in response to the electrical stimulation. Electrodes used for nerve stimulation are usually placed on the face (facial nerve monitoring) or on the wrist (ulnar nerve monitoring).

The Study:

In a simple but clever clinical study done in hospitals in Switzerland and Austria and published in the flagship specialty journal Anesthesiology, investigators have combined nerve stimulation for monitoring of muscle relaxation, with the effects of acupuncture.

By moving one of the wrist electrodes about 2 cm from its usual (ulnar nerve) location toward the center of the wrist, corresponding with the location of both the median nerve and the P6 point, investigators guessed they might achieve both goals – that is, monitor paralysis while providing an anti-nausea effect. The stimulator was set at 1Hz, that is one electrical impulse per second, for the duration of each case.

Placing the electrodes for monitoring and prevention of PONV

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