“Twilight” is a movie

Propofol bottles

How the advent of propofol — the drug associated with the deaths of Joan Rivers and Michael Jackson — changed the meaning of the term “sedation”

“Twilight! She has to have twilight,” insisted the adult daughter of my frail, 85-year-old patient. “She can’t have general anesthesia. She hasn’t been cleared for general anesthesia!”

We were in the preoperative area of my hospital, where my patient – brightly alert, with a colorful headband and bright red lipstick – was about to undergo surgery. Her skin had broken down on both legs due to poor circulation in her veins, and she needed skin grafts to cover the open wounds. She had a long list of cardiac and other health problems.

This would be a painful procedure, and there would be no way to numb the areas well enough to do the surgery under local anesthesia alone. My job was to figure out the best combination of anesthesia medications to get her safely through her surgery. Her daughter was convinced that a little sedation would be enough. I wasn’t so sure.

“Were you asleep the last time your doctor worked on your legs?” I asked the patient. “Oh, yes,” she said. “Completely asleep.”

“But she didn’t have general,” the daughter interrupted. “She just had twilight.”

Propofol revolutionized anesthesia care

Though “twilight” isn’t a medical term, people often use it to mean sedation or light sleep as opposed to general anesthesia. Most patients don’t want to be awake, even if their operation doesn’t require general anesthesia. They prefer an intravenous “cocktail” to make them oblivious to pain and unaware of anything that’s happening. Today, the main ingredient is likely to be an anesthetic medication called propofol.

Propofol came on the U.S. market in 1986 and revolutionized anesthesia care, though the public heard little about it before the deaths of Michael Jackson and Joan Rivers. For the first time, we had a medication that allowed patients to sleep through unpleasant procedures like colonoscopies and wake up quickly with no nausea or “hangover”.

But we soon learned that propofol causes other problems. In older patients and anyone with heart trouble, propofol can make the blood pressure drop dangerously low. It also reduces the drive to breathe. Trickling propofol into the IV line in exactly the right dose to keep a patient breathing well but not moving during surgery – that can be a real challenge.

There’s no magic way to mark the moment when a patient under propofol crosses the thin line between comfortably sedated and deeply unconscious. This can progress quickly to the point where the patient is not breathing at all. The results can be catastrophic.

Sedation or general anesthesia?

So is propofol sedation really “sedation”? Or is it really general anesthesia with an unprotected airway and no way to control breathing? General anesthesia without a safety net?

Part of the problem is confusion about the term “sedation”. Before propofol, when procedures were done under local anesthesia with sedation, surgeons used local anesthesia to numb the target area, and patients received medications like Valium or Demerol which helped them relax and eased any discomfort. But the patient was still awake. This technique is referred to today as “conscious sedation”.

Propofol sedation is different. Today, when surgeons say an operation can be done under “sedation”, they assume the patient will be asleep under propofol. The same is true for the gastroenterologist who needs to perform an uncomfortable endoscopy. Understandably, they want their patients asleep and still. Few patients want to be awake. On goes the propofol drip, and everyone is happy – most of the time.

What’s the difference between deep sedation and general anesthesia? Not much except semantics. If my patient is unconscious, then I’ve induced general anesthesia.

No more ether or chloroform

But wait. What about the nasty-smelling anesthesia gases, breathing tubes, and postoperative nausea? Don’t they always go along with “old-school” general anesthesia?

Anesthesiology has come a long way from the days of ether and chloroform, which made everyone vomit. Modern anesthesia gases like sevoflurane and desflurane are far more pleasant. They’re often tolerated better than propofol in terms of maintaining normal heart function and safe blood pressure. They clear out of the body quickly with normal breathing at the end of the operation.

Medicine has become so specialized that most physicians have little training in anesthesiology unless they enter the field. Many doctors never step into an operating room again after they finish the basic surgery rotation in medical school. They aren’t familiar with today’s operations. Even “minimally-invasive” surgery often requires general anesthesia and a breathing tube. Some physicians assume – and advise their patients – that sedation is always preferable to general anesthesia, even though that isn’t true.

There’s no reason to fear anesthesia, but every reason to respect it. The best choice of anesthesia technique will vary depending on the patient’s health and the type of procedure.

My 85-year-old patient? I decided to use a propofol drip, at a dose that made her completely unconscious. She couldn’t have tolerated the surgery otherwise. I took her blood pressure every two minutes, watched every breath she exhaled with a carbon dioxide monitor, and adjusted the propofol dose up and down to match the level of surgical stimulation. Airway equipment was ready in case her breathing needed support.

With all those precautions, my patient survived her surgery and woke up just fine. But I wouldn’t call her anesthesia “twilight”.



Joan Rivers 3

New York Post reporter Susan Edelman revealed on January 4 the name of the unfortunate anesthesiologist allegedly present on August 28 at Yorkville Endoscopy, during the throat procedure that led to the death of comedian Joan Rivers. She is reported to be Renuka Reddy Bankulla, MD, 47, a board-certified anesthesiologist from New Rochelle, NY.

Having her name made public will be a nightmare for Dr. Bankulla, as investigators will certainly target her role in Ms. Rivers’ sedation and the management — or mismanagement — of her resuscitation.

When the news of Ms. Rivers’ cardiac arrest and transfer to Mt. Sinai Hospital became public, many of us guessed that there might have been no qualified anesthesia practitioner — either anesthesiologist or nurse anesthetist — present during the case. The gastroenterologist and then medical director of the clinic, Dr. Lawrence Cohen, argued famously that the sedative propofol, which Ms. Rivers received, could be safely given by a registered nurse under his supervision, and that no anesthesiologist is necessary.

However, with the publication of the Centers for Medicare & Medicaid Services (CMS) report of September 5, it became clear that an anesthesiologist was definitely present. The anesthesiologist was identified only as “Staff #2″ in the report. She was interviewed by the CMS surveyors four days after the event, but said she was “advised by her legal representative not to discuss the case.”

Key pieces of information about what happened still haven’t been made public. Nonetheless, the surveyors gathered enough information to reach this conclusion:  “The physicians in charge of the care of the patient failed to identify deteriorating vital signs and provide timely intervention during the procedure.”

By any standard of care, the anesthesiologist clearly would be one of the physicians in charge.

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Regina santamaria

I still find it hard to believe that this happened to joan rivers despite having a board certified anesthesiologist the entire time administering propofol. While end tidal co2 is useful , my most useful tool is watching the patient breathe! Even if I have to put my hand on their chest to feel the chest rise. The only thing I can think of is that when the Joan lost her airway either by going into laryngospasm or simply not breathing, there wasn't the proper equipment ...Read More
Dr. Sibert: My Mom is who taught me the principle that nothing we do is easy, simple, or minor (ESM). She was my private office manager for 20+ years and very early on straightened me out about opining to patients anything I did for them was ESM. I'll never forget the TURP I administered 5mg IV diazepam to and then had to ventilate for 20 min. because of where he was on the bell shaped curve. Later I became an attorney and ...Read More

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Party animals 11:21

No one wants a hospital-acquired infection—a wound infection, a central line infection, or any other kind.  But today, the level of concern in American hospitals about infection rates has reached a new peak—better termed paranoia than legitimate concern.

The fear of infection is leading to the arbitrary institution of brand new rules. These aren’t based on scientific research involving controlled studies.  As far as I can tell, these new rules are made up by people who are under pressure to create the appearance that action is being taken.

Here’s an example.  An edict just came down in one big-city hospital that all scrub tops must be tucked into scrub pants. The “Association of periOperative Registered Nurses” (AORN) apparently thinks that this is more hygienic because stray skin cells may be less likely to escape, though there is no data proving that surgical infection rates will decrease as a result.  Surgeons, anesthesiologists, and OR nurses are confused, amused, and annoyed in varying degrees.  Some are paying attention to the new rule, and many others are ignoring it.  One OR supervisor stopped an experienced nurse and told to tuck in her scrub top while she was running to get supplies for an emergency aortic repair, raising (in my mind at least) a question of misplaced priorities.

The Joint Commission, of course, loves nothing more than to make up new rules, based sometimes on real data and other times on data about as substantial as fairy dust.

A year or two ago, another new rule surfaced, mandating that physicians’ personal items such as briefcases must be placed in containers or plastic trash bags if they are brought into the operating room.  Apparently someone thinks trash bags are cleaner.

Now one anesthesiology department chairman has taken this concept a step further, decreeing that no personal items at all are to be brought into the operating room–except for cell phones and iPods.  That’s right, iPods, not iPads.  This policy (of course) probably won’t be applied uniformly to high-ranking surgeons or to people like the pacemaker technicians who routinely bring entire suitcases of equipment into the OR with them.

What’s particularly irrational about this rule is that cell phones likely are more contaminated with bacteria than briefcases or purses, even if they’re wiped off frequently.  And I have to ask how an iPhone 6+ meets eligibility criteria while the barely-larger iPad mini doesn’t.  Again, please show me the data demonstrating that this will reduce infection rates, unless someone is making it a habit to toss briefcases and iPads onto the sterile surgical field.

Show me the money

I wish I could say that the driving force behind hospitals’ fear of infection is simply the wish for patients to get well. Unfortunately, it’s probably driven as much by financial motives as benevolent ones.  Today, Medicare won’t pay for care related to surgical site infections, and it fines hospitals whenever too many patients need to be readmitted within 30 days of discharge.  In 2014, a record 2610 hospitals–including 223 in California–were penalized, and will receive lower Medicare payments for all patients over the next year, not just those who were readmitted.

What does this mean at the grassroots level?

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I hate to repeat myself (not really); but once you understand that much of this is about breaking physicians to someone's saddle, it all makes sense. It's a lot more about power and control than it is about patient-care improvement. Ever notice how deeply the nursing profession is imbedded in this sort of busy-bodying? It's a great chance for groups of non-physician colleagues who've traditionally felt "oppressed" by doctors to get a little payback by nipping at our heels like snarly terriers. What they can't achieve ...Read More

Zach Barnes

Excellent post. I've participated on one of these "quality improvement" projects as they were required for residency completion (a whole other topic entirely, along the appears to be getting stuff done line). Being someone who values reason and rationality, it was very difficult to sit through and hear some of the just off the wall absurdities you endure in these meetings. We as a group and unfortunately the face of these policies (either in exclaim or blame) have to stand up or all day we ...Read More



“I’m here to say ‘Yes, they can,’ which is different from ‘Yes, they always do,’” says James Moore, MD, President-Elect of the California Society of Anesthesiologists (CSA).

To the contrary, enthusiasm for electronic medical records (EHRs) is part of a “syndrome of inappropriate overconfidence in computing,” argues Christine Doyle, MD, the CSA’s Speaker of the House.

The two physician anesthesiologists (and self-identified “computer geeks”) squared off in a point-counterpoint debate in New Orleans as part of the American Society of Anesthesiologists (ASA) annual meeting, with Dr. Moore defending the benefits of EHRs and Dr. Doyle arguing against them. Dr. Doyle chairs the ASA’s Committee on Electronic Media and Information Technology, while Dr. Moore leads the implementation of the anesthesia information management system (AIMS) at UCLA.

Legibility, accuracy, quality

Dr. Moore defined safety in anesthesia care as “minimizing patient injury resulting from or occurring during anesthesia, and keeping surgeons from harming patients any more than they have to.” He said that computerization contributes to safe anesthesia care by improving legibility, offering clinical decision support with readily available reference information, and providing alerts and reminders.

Computer tracking of the anesthetized patient’s vital signs is more accurate, Dr. Moore said. It prevents the “normalization” of blood pressure that tends to appear on the paper record. Quality reports are easier to generate and outcomes are easier to measure with EHRs in place, he noted. “Postop troponin levels and acute kidney injury are easy to track.”

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Clark Venable

EHR and CPOE are a disaster. In the age of physician shortages, it is unwise to make doctors slower and less efficient by requiring them to do peripheral items and not direct patient care. These thing were sold to us as an integrated system in which we could access records from other systems easily. That never materialized....nor was it intended. Instead these are instruments to make RAC audits easier, track physician behavior, limit ordering choices, and ultimately implement algorithmic medicine.


The anesthesia care team has a long-standing record of safety

“Fighting against those who want to change things is a futile strategy,” declared Jason Hwang, MD, MBA, keynote speaker at the opening ceremonies of the American Society of Anesthesiologists’ annual meeting in New Orleans on Saturday, October 11. “You can’t defend a profession by putting up regulatory and payment barriers to stop the barbarians at the gates.”

Dr. Hwang is a co-author of  The Innovator’s Prescription: A Disruptive Solution for Health Care, the winner of the 2010 Book of the Year award from the American College of Healthcare Executives. An expert on the subject of disruptive innovation, Dr. Hwang told the audience of anesthesiologists from more than 90 countries that the Perioperative Surgical Home (PSH) concept offers an integrated solution to healthcare that can help the profession of anesthesiology adapt, survive, and prosper.

He used the example of Apple Inc. to illustrate how a company can thrive while other huge competitors failed because they yielded to “the irresistible temptation to keep doing what they already did best.”

Faster horses, bigger hard drives

If Henry Ford had asked customers what they wanted, Dr. Hwang said, they would have answered “faster horses”. If you asked people what they wanted from their computers 10 years ago, they would have answered bigger hard drives, more memory, and faster processors. Nobody would have said they wanted a phone. But Apple redefined the business with smartphones and tablets that created their own market, and Apple controls the entire integrated product.

Anesthesiology’s chief problem has been complacency with the status quo, Dr. Hwang said. Profitability has been greatest in the operating room, while the areas of preoperative and postoperative care were ripe for encroachment by hospitalists and other practitioners.
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After I initially commented I seem to have clicked on the -Notify me when new comments are added- checkbox and now wwhenever a comment is added I recieve four emails with the exact same comment. There has to be an easy method you can remove me from that service? Cheers!
Wonderful article! This is so insightful about anesthesia, and it really gives an overview about the future of anesthesia. With so many current advances in technology, the future of anesthesia is certainly open. Thanks so much for sharing this info!