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.
