John E. Tetzlaff

Nonoperating room anesthesia for the gastrointestinal endoscopy suite.

Anesthesia services are increasingly being requested for gastrointestinal (GI) endoscopy procedures. The preparation of the patients is different from the traditional operating room practice. The responsibility to optimize comorbid conditions is also unclear. The anesthetic techniques are unique to the procedures, as are the likely events that require intervention by the anesthesia team. The postprocedure care is also unique. The future needs for anesthesia services in GI endoscopy suite are likely to expand with further developments of the technology.

Electromagnetic interference in a cardiac pacemaker during cauterization with the coagulating, not cutting mode

Electromagnetic interference in pacemakers has almost always been reported in association with the cutting mode of monopolar electrocautery and rarely in association with the coagulation mode. We report a case of electrocautery-induced electromagnetic interference with a DDDR pacemaker (dual-chamber paced, dual-chamber sensed, dual response to sensing, and rate modulated) in the coagulating and not cutting mode during a spine procedure. We also discuss the factors affecting intraoperative electromagnetic interference. A 74-year-old man experienced intraoperative electromagnetic interference that resulted in asystole caused by surgical electrocautery in the coagulation mode while the electrodispersive pad was placed at different locations and distances from the operating site (This electromagnetic interference did not occur during the use of the cutting mode). However, because of careful management, the outcome was favorable. Clinicians should be aware that the coagulation mode of electrocautery can cause electromagnetic interference and hemodynamic instability. Heightened vigilance and preparedness can ensure a favorable outcome.

Reentry of anesthesiology residents after treatment of chemical dependency—is it rational?

Although chemical dependency has been widely acknowledged as the most significant occupational safety issue for anesthesiology, it is neither new nor is it restricted to physicians or the United States. Early work with cocaine by William Halsted to produce topical and conduction anesthesia also resulted in his addiction to cocaine. Almost as soon as anesthesiology began to be recognized as a unique medical specialty, physician anesthesiologists were known to have a high incidence of addiction and suicide [1]. This elevated risk has not changed significantly for the past three decades [2,3], and although first reported in US physicians giving anesthesia, it is reported with the same alarming incidence in the United Kingdom [4] and among nurse anesthetists [5]. Although addiction carries substantial risk to health wherever it occurs, addiction to anesthesia drugs has great lethality. Suicide is highly associated with chemical dependency on anesthesia drugs [6], and unfortunately, death is often the first sign of this form of addiction [7,8]. Despite increasingly widespread recognition of the seriousness of this problem, improved methods to prevent diversion of controlled substances, and education about the risks, the incidence of addiction has not changed [9], nor has the morbidity [10]. There is clearly an association between risk of addiction and the handling of anesthesia drugs [11]. Several reasons for this association have been proposed in the anesthesiology literature. Some of the causes are thought to be early drug experimentation, prior addictive tendency [10], and other high-risk behavior [12]. An interest in pharmacology undoubtedly is a factor that draws physicians to anesthesiology. In the course of learning to give anesthesia (and beyond), the realities of stress, production pressure, low self-esteem, and working alone undoubtedly contribute to self-medication and chemical dependency. Growing experience with administering anesthesia drugs creates the fallacy of control, which makes the transition from self-medication to chemical

Special Problems in Anesthesia

The practice of medicine requires the highest standards of professionalism for personal behavior during clinical care education and research. Since the practice of anesthesiology is the practice of a medical specialty, this fully applies to anesthesiology. The anesthesiologist has the responsibility to place the needs of the patient above his/her own, and to practice with altruism, beneficence, and to fully respect the patient’s autonomy and diversity. Respect for rules is an expectation, especially requirements for medical licensure and board certification. Deadlines are absolute and missing deadlines is a serious breach of professionalism that can have adverse consequences. The need to respect resources and economical use of supplies, disposables, equipment, and drugs is an increasing reality of anesthesia practice. Determining risk and recommending interventions to improve surgical outcome are consultant tasks that are an expected part of professional anesthesiology duties. Some elements of hospital functioning, such as acute pain management, transfusion practice, and operating room scheduling can be tasks best performed by an anesthesiologist, and hence are responsibilities accepted as part of a consultative anesthesiology practice.

Anesthetic Issues for Orthopedic Surgery in Patients with Rheumatoid Diseases

Patients with rheumatoid diseases present complex management issues in the perioperative period because of the pathophysiologic consequences of these diseases and other comorbidities. The anesthesia team is being increasingly required to determine the suitability of patients for operative procedures. Extremes of age, surgical complexity, and coexisting illness place surgeons in the position of seeking “medical clearance” from the anesthesia team for an increasing number of patients, emergent and elective. A systematic approach to optimizing these patients would appear rational.

Perioperative Pain Management and Orthopedic Surgery

Given the nature of orthopedic surgery, moderate to severe pain should be anticipated with almost every major procedure. To achieve a reasonable degree of patient satisfaction, a well-designed plan to control acute pain should be a part of every procedure. Ideally, the plan should be presented to patients before they go to the operating room so that they will understand their role in the plan and can participate fully. This approach assures the patient that some intervention to deal with acute pain will be implemented before excruciating pain is felt.

Atlas of Regional Anesthesia, Third Edition David L. Brown, M.D.Saunders (2005) ISBN 1416022392, 256 pp., £88.00

When asked to review the third edition of Dr. avid Brown’s Atlas of Regional Anesthesia, I was leased to be chosen. As a student and teacher of egional anesthesia, I have recommended the preious editions of this book as the best choice for a ovice who wants a practical approach to the “how o’s” for any given block. It is also the best starting oint for experienced staff who want to refresh or xpand their technical portfolio for regional aneshesia. Improving something that is excellent is difcult, and one of the golden rules of anesthesiology s “the enemy of good is better.” Dr. Brown demnstrates with this work that even the best rule has xceptions. The excellence of the previous editions remains ndiminished. The artwork is aesthetically pleasing nd presented in the text in an ergonomically conenient manner for readers planning to use the text nd illustrations in tandem. The vast majority of the llustrations have a practical value, with minimal edundancy. Most important, the eyes of the artist ere obviously guided by the hands of an expert in he use of regional anesthesia for surgery and the elief of pain. The illustrations reflect the experince of the author in getting the block done and, erhaps more important, communicating this skill o a novice who has never even seen the block one. The text is carefully created to serve the urpose of an atlas—to get the block done. It resists he temptation to teach comprehensively, leaving hat to other definitive references, such as Dr. rown’s own textbook. Indications for blocks and hoice of local anesthetics are presented concisely n the practical manner that is the hallmark of this ext. Many students of regional anesthesia who have ecome teachers have adopted Dr. Brown’s “three ’s”—patient selection, pharmacologic choices, and earls—as a means of presenting blocks to novices. his approach is consistently followed throughout the tlas. In contrast with others, Dr. Brown does not esitate to offer his expert opinion about how to do hings, even in the few instances where other experts isagree. Dr. Brown does not digress into these deates, which would detract from the purpose of this tlas. o