Posts Tagged ‘patient safety’

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.

What is fentanyl?

Fentanyl is an opioid pain-killer in the same class as morphine or Demerol, meaning that it acts on the same receptors in the brain to lessen the subjective experience of pain. It appeared on the market in 1960, and quickly gained wide use in anesthesia practice.

Fentanyl is potent and works fast, which makes it very effective in treating the intense stimulus of surgical pain, and its peak effect lasts only a short time. It’s also inexpensive, which makes it attractive in an era of cost containment in healthcare.

When I started my anesthesia residency, we assumed that since fentanyl’s analgesic and euphoric effects were so brief, short-term exposure to the drug wouldn’t increase a patient’s risk of long-term narcotic abuse. For the first few years, fentanyl was kept in unsecured medication carts in the operating rooms along with Benadryl, lidocaine, and other commonly used medications.

But anesthesiology departments quickly learned that fentanyl did indeed have high abuse potential. Its pleasurable “high” and rapid onset proved irresistible to some people, and deaths from overdose occurred all too often among medical personnel. Now, we track every microgram of fentanyl used or discarded during surgery.

Fentanyl stayed quietly under the radar for decades as an IV drug useful primarily in anesthesiology practice. But it began to see more use in the treatment of chronic pain — as transdermal patches, or “lollipops” for absorption by mouth. And with its increased availability came a higher risk of abuse. The well-publicized death of the musician Prince in 2016 from an accidental overdose propelled fentanyl into fame.

Today fentanyl is making headlines as the drug responsible for an ever-increasing number of opioid overdose deaths. Cheap to synthesize, it’s being laced into heroin and illegally made into pills that look just like oxycodone. People don’t have any way of knowing how much they are taking, and they die because they stop breathing.

Of course, illegal fentanyl abuse is the polar opposite of administering fentanyl responsibly as a licensed anesthesia professional who is monitoring the patient’s every breath. But we’ve learned that opioids, even when legally and carefully administered with the best intentions, may have unintended consequences.

Pain relief can lead to more pain

The key fact, often poorly understood by physicians — let alone the general public — is that treating pain with opioids can lead to more pain, a phenomenon known as “opioid-induced hyperalgesia”.

This is different from tolerance to the pain-relieving effects of opioids. Most people understand that if you start taking any narcotic — whether morphine, oxycodone, or fentanyl — over time you will become “tolerant” to the drug’s effect and will need more of it to achieve the same level of pain relief.

Opioid-induced hyperalgesia, or “OIH”, is a different problem. The definition of hyperanalgesia is abnormally heightened sensitivity to pain. OIH is defined as hypersensitivity to pain that occurs as a result of opioid use. When surgical patients receive opioids while under anesthesia, several studies have demonstrated increased opioid requirements after surgery, and worse, not better, pain scores.

An excellent 2016 review article in the journal Anesthesiology pointed out that the potential onset of OIH “should be considered when opioids are administered” to patients under anesthesia. It may well be that short-acting opioids such as fentanyl are worse offenders in terms of provoking OIH than longer-acting ones, as OIH increases when pain relief wears off and opioid doses must be repeated.

Do we need to use opioids during anesthesia?

Actually, we don’t. That has been the most surprising fact I’ve learned in recent years, as I’ve modified my practice in light of America’s lethal opioid epidemic.

There’s little reason to use fentanyl to block the unconscious patient’s blood pressure and heart rate responses during surgery, or the discomfort of having a breathing tube inserted. Other non-opioid anesthesia medications can do that just as well, without the risk of OIH.

In fact, a recent editorial from UCLA suggested that we don’t need to give opioids during surgical anesthesia at all, and that we would be better off reserving them for postoperative pain control. We can use other techniques — inhaled anesthetics, regional nerve blocks, epidurals, non-opioid pain medications — in a multimodal approach to treating painful stimuli during and after surgery. We can change our public image from “the docs with good drugs” to “proactive healers of our national opioid addiction epidemic.”

In light of all this information, I’m not sure I want my anesthesia practice associated with the use of fentanyl at all. I may be paranoid, but I suspect it’s only a matter of time until some clever plaintiff’s attorney sues anesthesia providers, claiming that a patient’s addiction was spawned by a first exposure to fentanyl during surgery. Who needs that misery?

As Joseph Heller wrote in Catch 22, “Just because you’re paranoid doesn’t mean they aren’t after you.” Enough said.

(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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How reporter Jan Hoffman and the New York Times manage to insult female physicians and get their facts about anesthesia so wrong all at the same time.

My husband and I, both anesthesiologists, enjoy our Sunday mornings together — coffee, the New York Times, a leisurely breakfast. No rush to arrive in the operating room before many people are even awake.

Today, though, seeing reporter Jan Hoffman’s front-page article in the Times — “Staying Awake for Your Surgery?” — was enough to take the sparkle out of the sugar. Her article on how much better it is to be awake than asleep for surgery reminded me why I left a plum job as a reporter for The Wall Street Journal to go to medical school — because reporters have to do a quick, superficial job of covering complex issues. They aren’t experts, but seldom admit it.

Physician anesthesiologists across the country are likely to face patients on Monday morning who wonder if they ought to be awake for their surgery. The answer to that question may well be “no”. But according to Ms. Hoffman, that answer reflects “physician paternalism”, and makes us opponents of the “patient autonomy movement”, because a patient should have the right to choose to be awake.

It’s not that simple.

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Six-year-old Caleb Sears:  His death was preventable

I’m not a pediatric anesthesiologist. Most of us in anesthesiology – even those who take care of children in the operating room or the ICU every day – probably will never give anesthesia to a child in a dentist’s or oral surgeon’s office. So why should we care what happens there? Dental anesthesia permits and regulations, after all, are under the authority of state dental boards, not medical boards.

The reason we should care is that healthy children have died under anesthesia in dental office settings, children like Marvelena Rady, age 3, and Caleb Sears, age 6. Unfortunately, they aren’t the first children to suffer serious complications or death in our state after dental procedures under sedation or general anesthesia, and unless California laws change, they won’t be the last.

In 2016, officers and past presidents of the California Society of Anesthesiologists (CSA) have made multiple trips to meetings of the Dental Board of California (DBC) to discuss pediatric anesthesia. We’ve provided detailed written recommendations about how California laws concerning pediatric dental anesthesia should be updated and revised. We’ve explained in testimony before the Dental Board, and in meetings with lawmakers, why we believe so strongly that the single “operator-anesthetist” model (currently practiced by dentists and oral surgeons in many states) cannot possibly be safe.

The DBC on December 30 published new recommendations for revision of California laws pertaining to pediatric dental anesthesia, posted them on its website, and sent them to the Senate Committee on Business, Professions, and Economic Development. But these recommendations ignored many of our concerns, and don’t go nearly far enough to protect children.

Further, the DBC cites statistics claiming that pediatric dental anesthesia is currently safe. But there is no database! The Dental Board has admitted to discarding records after review. They have reported on “only nine” recent cases involving death, ignoring other tragic cases of permanent brain damage and prolonged ICU admissions. Pediatricians in California recently surveyed 100 of their members and found that 29 of them — nearly one-third — knew of patients in their practices who had experienced adverse events in a dental office.

What is a single “operator-anesthetist”?

You may never have heard of a single “operator-anesthetist” because such a thing doesn’t exist in medical practice.

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Is it always wrong for a surgeon to book cases that will be done in two operating rooms during the same timeframe?

If you’ve paid much attention to the overheated commentary on social media since the Boston Globe published its investigative report, “Clash in the name of care“, you might easily conclude that the surgeon who runs two rooms ought to be drawn and quartered, or at least stripped of his or her medical license.

John Mandrola, MD, a Kentucky cardiologist who I’ll bet doesn’t spend a lot of time in operating rooms, weighed in on Medscape with a post called “The Wrongness of a Doctor Being in Two Places at Once“, accusing surgeons of hubris and greed.

Respectfully, I disagree.

The Globe’s story tells the dramatic tale of how a prominent surgeon at Massachusetts General Hospital often scheduled two difficult spine operations at the same time. According to the Globe’s reporters, the surgeon typically moved back and forth between two operating rooms, performing key parts of each procedure but delegating some of the work to residents or fellows in training.

On one particular day, a complex case ended with a tragic outcome. The patient, a 41-year-old man, sustained spinal cord injury at the level of his neck, leaving him permanently unable to move his arms or legs. Another prominent MGH surgeon leaked details of the case to the press, and was summarily fired.

Of course, I have no special access to information about what goes on at the MGH, and can’t comment on the specific cases highlighted in the Globe’s report. But I’ve been giving anesthesia for a long time in first-class hospitals. On countless occasions, I’ve seen surgeons run two rooms, and have administered anesthesia to a patient in one of them.

Have I ever seen a patient come to harm because the surgeon scheduled concurrent cases?  No.

Have I ever been annoyed because a surgeon delayed the start of my patient’s case because of the demands of the case in the other room? Yes, but I always agreed with the decision to delay, and the wisdom behind it. If the surgeon is at a critical portion of the first case, we have no business starting the second case until the surgeon gives the go-ahead.

Have I ever been thankful that the surgeon had two rooms? Yes indeed. Here’s why.

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