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 »


Statins – good for the heart, bad for the brain?

September 23, 2008

A study in the Canadian Medical Journal, accompanied by a commentary, looks at statins and postoperative delirium.

This condition (“an acute change in mental status that is worrisome to patients and families”) is a big concern for many elderly patients (and their families) having major surgery. Unfortunately we don’t yet know enough about the predisposing factors and direct causes to do very much about preventing postoperative delirium, apart from avoiding some things which are obviously bad for all patients (e.g. low blood pressure, inadequate oxygen, etc). Delirium increases the average length of a hospital stay by about a week, is associated with a variety of complications and increased costs, and may even be linked to permanent brain deficits.

This study suggests that statin drugs predispose to postoperative delirium. Is the conclusion correct? Should it change medical practice, which currently strongly favors the continuation of statins after surgery because of their protective effect on the heart? Read the rest of this entry »

Statins – not just for cholesterol

September 10, 2008

Statins – the drugs like Lipitor, Crestor, Zocor, Lescol and others – do more than reduce your cholesterol. Several studies have shown that these drugs protect people with heart disease having major non-heart surgery. The beneficial effect seems to come from anti-inflammation properties common to all statins.

The latest, and perhaps strongest piece of evidence so far comes from a new study in the Netherlands in which patients having vascular (blood vessel) surgery – known to have the highest risk of heart attack after surgery – were given a long-acting statin – fluvastatin – and continued on it after leaving the hospital. The statin cut the rate of heart attack and of myocardial ischemia (angina, or where the heart muscle doesn’t get enough blood supply) by about 50%. Read the rest of this entry »

Information overload during the pre-anesthesia interview

September 8, 2008

How much can you learn all in one go? Cognitive science has established that on average we can hold only seven or so “chunks” of new information.

In this Sept 2008 study in Anesthesia & Analgesia, patients interviewed in a pre-anesthesia clinic in Boston were heavily overloaded with information by nurses and doctors. Audio recordings showed that nurse practitioners attempted to transmit on average more than 110 pieces of information during the interview. The doctors came in with roughly 50 apiece. Read the rest of this entry »

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.

Read the rest of this entry »

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 »

“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 »

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.

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.