No, I’m not talking about putting fentanyl into my own veins — a remarkably bad idea. I’m questioning the habitual, reflex use of fentanyl, a synthetic opioid, in clinical anesthesiology practice.

I’ve been teaching clinical anesthesiology, supervising residents and medical students, in the operating rooms of academic hospitals for the past 18 years. Anesthesiology residents often ask if I “like” fentanyl, wanting to know if we’ll plan to use it in an upcoming case. My response always is, “I don’t have emotional relationships with drugs. They are tools in our toolbox, to be used as appropriate.”

But I will say that my enthusiasm for using fentanyl in the operating room, as a component of routine, non-cardiac anesthesia, has rapidly waned. In fact, I think it has been months since I’ve given a patient fentanyl at all.

Here’s why.

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7 COMMENTS

karen

Dear Gabriel: Choice of analgesia depends on the type of problem, the duration of analgesia needed, the patient's underlying co-morbidities, and history of pain medication use. Multimodal analgesia is very helpful. Short-acting narcotics -- fentanyl, remifentanil -- are not very effective for prolonged postoperative pain. Regional blocks/epidural analgesia may be very useful. A book could be written (and probably has been) on this topic! Best, Karen Sibert, MD

Gabriel

can you please list out some of your adjuvants or alternatives? I commonly see posts like this, and I agree, however, I would like to have a little more guidance other than "don't use it"

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(This post chronicles the recent Los Angeles visit of ASA President Jeff Plagenhoef, MD, and his Grand Rounds presentation at USC. It originally appeared on the website of the California Society of Anesthesiologists. Above, Surgeon General Jerome Adams, MD, MPH, left, with Dr. Plagenhoef.)

“Who kicked whom off the anesthesia care team?” asked ASA President Jeff Plagenhoef, MD, FASA. Which professional association refuses to work amicably with the other, he inquired of his audience at the University of Southern California on September 15, as he delivered a powerful Grand Rounds address to the Department of Anesthesiology.

In his talk, “Professional Citizenship:  Responsibilities Shared by All Anesthesiologists”, Dr. Plagenhoef emphasized that physician anesthesiologists and the American Society of Anesthesiologists (ASA) fully support nurse anesthesia practice within the physician-led anesthesia care team. In his practice as Chair of the Department of Anesthesiology at Baylor Scott and White Hillcrest Medical Center in Waco, Texas, Dr. Plagenhoef works with nurse anesthetists and with certified anesthesiologist assistants (CAAs).

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5 COMMENTS

Peter M. Lucas, MD

Dominica; Yes, I have been following the development of Anesthesia Assistants. It looks like they may provide a good solution. There is a significant regulatory hurdle for them. Furthermore, if their salary requirements are indeed very close to that of anesthesia nurses, it will be difficult to fit them into many small to medium practices.
Great article and I do believe there is a time and place for an anesthesia care team. I chose to be in a physician only anesthesia team for my practice. Here are my in-depth thoughts. https://krissymd06.com/2017/10/19/the-physician-anesthesiologist-vs-crna-debate/ Thank you Karen for your outstanding opinions!!

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The Practical Art of POCUS

The longer you practice a profession, the easier it is not to bother to learn the next new thing. We may think we’re doing just fine without that new drug, or that new piece of expensive equipment. We’ve seen how the new drug sometimes turns out to have more side effects than benefits, and how the equipment may gather dust in the corner because no one really needed it in the first place.

That isn’t going to happen with point-of-care ultrasound, or “POCUS”, I’m willing to bet. As I learned at a weekend conference on POCUS, jointly hosted by the anesthesiology departments at UCLA and Loma Linda University, the practical applications for bedside patient care are multiplying, and the technology is improving all the time. Ultrasound isn’t just for cardiologists and radiologists any more.

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Dr. Sibert, thank you very much for attending the workshop. Your post elegantly describes the overall message of what this course is focused on. It is my sincere hope that our specialty continues to embrace point of care ultrasound to improve our physical examination, as other acute care specialties have already done. Websites such as www.foresightultrasound.com and www.pocuseducation.com provide more educational material, as well as information for our course for next year. Again, thank you very much for your interest, and we hope ...Read More

Eduardo

(Errata sheet-Corrected version) Very interesting topic and right in point for me: I recently (last week) went to Buenos Aires, Argentina Anesthesia Annual Congress and this year much emphasize was done on ‘hands-on’practices and a lot in Ultrasound procedures and Regional Anesthesic US assisted. I can feel much anxiety and challenged by a shock of new skills that are abruptly for me, got in surface, even I’ve been good at the art of 'hand skills' and observation (can’t find proper slight adjectives for description). I got ...Read More

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Emory University held graduation ceremonies on August 5 for the 2017 Class of Anesthesiologist Assistants (AAs), who received Masters of Medical Science degrees. While the traditional academic regalia can’t fail to evoke Harry Potter in the minds of many of us, there is some magic in the processional and the music that always makes graduation a moving, meaningful event. I had the honor of delivering the commencement address, reprinted here.

Distinguished faculty, graduates, honored guests:

It is a great pleasure and an honor to be here, and to congratulate all the graduates of the Emory University Class of 2017 on your tremendous accomplishment. Just think about all you have learned in the past two years! You’ve transformed yourselves into real anesthesia professionals, able to deliver first-class care to patients at some of the most critical times in their lives.

Today is a great time to become an anesthesiologist assistant. Just two days ago, Dr. Jerome Adams was confirmed as our country’s Surgeon General. He is the first-ever physician anesthesiologist to have that honor. Even better, he is from Indiana, where he was the State Health Commissioner, and of course Indiana is among the states where CAAs are licensed to practice. We know that Dr. Adams understands the principles of the anesthesia care team. Dr. Adams gets it – who AAs are, what you do, and how well qualified you are to care for your patients.

Another happy thought – the Secretary of Health and Human Services today is Dr. Tom Price from Georgia, an orthopedic surgeon, and a former Representative in Congress. His wife, Betty, is a physician anesthesiologist who currently serves in the Georgia state legislature.

Whatever your opinions about politics (and believe me, we’re not going there today), whether your blood runs red or blue, I think we can all celebrate the fact that we now have people in key positions who understand anesthesia; whose presence in Washington is great for AAs, for patients, and for the practice of safe, team-based anesthesia care.

All About Great Medical Discoveries

As I thought about what to say to you today, the first thing that occurred to me is that this summer marks 30 years since I finished my anesthesia training. You might be curious to know if I ever had any second thoughts, any regrets about that career choice. My answer is a resounding “no”.

I was lucky enough to get interested in anesthesia at an early age. I brought something to show you. This book was published in 1960. It’s called All About Great Medical Discoveries, and I read it when I was a little girl about 8 or 9 years old, in Amarillo, Texas. Here’s what it had to say about anesthesia, in a chapter called “The Conquest of Pain”:

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6 COMMENTS

David Denyer

that commencement speech was the best thing Ive read in a long time. Wisdom at every point! Thank you for all that you do for our profession and cant wait to work out there in California soon!

Gina Scarboro

Dr. Sibert, Thank you for the words of wisdom and encouragement for the Emory AA Program graduates. We appreciate your leadership and example of professional advocacy! Best, Gina Scarboro CAA

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The art of deep extubation

Fair warning — this post is likely to be of interest only to professionals who administer anesthesia or may have to deal with laryngospasm in emergency situations.

There are two schools of thought about how to extubate patients at the conclusion of general anesthesia:

Allow the patient to wake up with the endotracheal tube in place, gagging on the tube and flailing like a fish on a line, while someone behind the patient’s head bleats, “Open your eyes!  Take a deep breath!”

Or:

Remove the endotracheal tube while the patient is still sleeping peacefully, which results in the smooth emergence from anesthesia like waking from a nap.

It will not require much subtlety of perception to guess that I prefer option 2. It is quiet, elegant, and people who’ve seen it done properly often remark that they would prefer to wake from anesthesia that way, given the choice.

There is art and logic to it, which I had the pleasure of learning from British anesthesiologists at the Yale University School of Medicine years ago.

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20 COMMENTS

Sunny

Too classy in your response above, Dr. Sibert. I liked reading your perspectives as well as the doc over at anesthesia consultant, who prefers not to do deep extubations. As trainees its easy to "memorize" which attending "likes" what and make our supervisors happy, but in doing that we are wasting our own time. The key is to learn the pros and cons of each attending's method, take the time to read and ponder on them, and one day (hopefully!) choose our own. Of course as ...Read More

Rahmat

Thank you for the article..I just succesfully extubated my patient with poorly controlled asthma by using this technique. A Very smooth emergence achieved.

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