My idea of “Demand Anesthesia” is not liked by many senior anesthesiologists including my late teacher Dr. Bhojraj. Their objection to this technique is that the patient responds in between which is likely to result in adrenaline secretion and may result in hypertension, ventricular fibrillation and arrest. Demand anesthesia is a vigilant anesthetic technique which needs continuous watch of the depth of anesthesia by signs of light anesthesia like
When any one of the signs is exhibited you are supposed to administer additional dose of Thiopentone till the reflex is suppressed. Far too often appearance of signs of anesthesia means you have to give additional sedatives and analgesics like Diazepam and Pethidine or Pentazocin or even stronger pain relieving drugs. All one is supposed to do is the balance the quantity of drug given and reaction of the patient to the stimuli. People are really worried about the cumulative effect of drug in post op period. But the patients are comfortable. Their O2 saturation does not fall and if by any chance the effect of drug persists as trickle of O2 though the nasal catheters tides over. This technique has been tried in many nursing homes without Boyle’s apparatus to deliver Nitrous Oxide-Oxygen and inhalational anesthesia. In my practice I have extensively tried this technique especially in cystoscopic procedures and orthopedic procedures like major fractures in very aged patient. Surgeons are very happy with the procedures since they find their patients awake and comfortable in post-op period. Vital parameters (signs) are stable and well maintained. Though anesthesiologists do not believe in this technique, my advice to them is “to see and then believe”. Those who have seen this technique are converted and like the technique. In a difficult situation it comes in handy.
Friday, June 6, 2008
Anesthesia on Demand
Reporting your observations: Beyond the call?
A senior urologist had taken a patient aged 82 for cystoscopy. The surgeon was in some doubt about why he was doing the cystoscopy, but since the patient had complaints he did not want to miss anything serious. I was about to cannulate a vein for anesthesia on the left forearm which was abducted on a arm board when I noticed a thumb sized vein on the chest wall. I wanted him to see it. As soon as he saw it he know that he had missed something big. He removed his gloves and put his hand on the upper part of the abdomen. He later confirmed that it was a big gastric carcinoma with complete blockage of the vena cava. Needless to say, the scopy was abandoned.
My point is that your should report your observations to the surgeon. I asked my students whether they narrate their observations. Some did not respond, some said that it is not our job. In my opinion one of our duties is to guard the patient’s interest; if you observe anything significant report it since silence could harm the patient. When I taught, I presented my private practice cases to my students as problems, I asked them whether they would proceed with anesthesia, refuse anesthesia, or would they like to know what happened to the patient. I made them think about it and discuss it in the next meeting. In this manner they learned much more than what text books could teach them.
Treating the whole patient
A close friend’s relative who had just returned from UK after his fellowship needed my help for an emergency. He wanted to transfuse the patient with at least 2 units and he gave me a call when the patient was ready. The nursing home was close to our house. When I arrived at the nursing home I was taken to the changing room. In the surgeon’s room I read the case paper. I checked with the ward boy to make sure that the paperwork belonged to the patient who was in for surgery. I glanced through the notes; the patient was about 38 years female. There was no mention about the menstrual history. When I went in the operation theater I noticed that the patient was very anxious about her survival and was worried about her son who was about 16-17 years and was by himself. I asked the surgeon about the menstrual history; he said that it was not relevant and it was not mentioned. He also said that the father of the son is a merchant marine (shippy /sailor) and has not come home for 3 years. Even then my diagnosis from the very look of the patient was different from their tentative diagnosis of a burst gall bladder. The planned incision was vertical, long parallel to the mid line extending from below the umbilicus to the costal margin. I suggested that they open the abdomen through the lower part of the planned incision (paraumbilical) and they agreed. They took about a 3 inch incision in the paraumbilical region with a further plan of extending it upwards. I was watching as the incision was made. The peritoneum in the paraumbilical regions looked black. I asked them to open the peritoneum and keep the suction ready. On opening, a black liquid gushed out and it filled the suction bottles. When the fluid was almost drained I requested them to extend the incision site down to symphysis pubis and feel for the tube-ovarian mass. They felt the mass which was brought out through the incision. This confirmed that it was a case of burst tubal pregnancy. They excised the mass and they were worried about the patient’s condition as the fluid drained was nearly 2 liters or more. I assured him that this is altered blood and the patient is well and they need not worry about the life of the patient. They administered a good peritoneal lavage and took out all the blood clots and closed the abdomen.
As we were having tea after the patient had been shifted to the bed, the team asked me about my diagnosis. My answer was the very look of the patient was diagnostic of burst tubal pregnancy and not that of a gall bladder rupture. I told them that this was my third case with similar circumstance and something I would not forget in my life time. Why had I asked them about menstrual history? Well…in a female patient usually it is recorded. Initially I had not suspected their diagnosis of gall bladder rupture but the very anxious look of patient, concern about her life, fully conscious, beads of perspiration on the face were very diagnostic as compared to burst gall bladder where the patient looks very toxic. That is also why I was continually looking at that small incision layer by layer and the black peritoneum clinched my diagnosis. The team told me that they are not going to tell the diagnosis to the patient but simply assure her that she would not be pregnant again (a great topic for a discussion on ethics in medicine) since they had ligated both the tubes. The patient must have understood and the son was not told about the bilateral tubal ligation as it would have been embarrassing.
In a similar case of exploratory laparotomy; all the surgeon knew is that had to open the abdomen to find the cause. The surgeon went to wash up; the patient was brought in a wheel chair. The patient was an anxious looking young female, sweating all over the body. I informed the surgeon about my suspected diagnosis of a tubal pregnancy and altered my method of anesthesia accordingly. The surgeon opened the abdomen to find the tubal pregnancy. Again, after the operation was completed and patient was shifted to the bed, the surgeon expressed his surprise about my diagnosis before the patient was opened. I had to tell him about the typical anxious look in a young female, full of perspiration all over and most importantly no toxicity.
You have to treat the whole patient.
