Wednesday, March 5, 2008

Enigmatic

During a recent discourse on end-of-life care I realized that anesthesia is a very misunderstood specialty. Basically a topic about drug-induced comatosed patients turned to various items related to anesthesia - like paralyzing medications, propofol induced comas, and the need for pain control these situtations.

What I found interesting was that the physician, with many years of experience dealing with dying patients and ICUs, didn't really know a great deal about an anesthestic state produced when one creates a drug coma. He didn't remember what drugs were used to cause muscular paralysis either. A couple students trying to be helpful shouted out succinylcholine.

"Well, yes, that does cause paralysis", I thought, "but for a very limited time (2-10 minutes)". More likely he was referring to the longer acting non-depolarizing muscular antagonist - like vecuronium or even pancuronium (since we're talking about dying ICU patients here). But no one brought these up. Multiple suggestions of a depolarizing blocker, but nothing else. A lot of places don't even use sux anymore because of the side effects, but I'm going off on a tangent here.

He then went on to discuss whether pain meds were needed in these types of comatose patients. What amazed me was that he wasn't sure if they needed them or not. Some of my peers suggested that propofol was useful to prevent pain. Hm, news to me. I thought that opiates and other painkillers were used for this, but maybe, again, they were thinking back on their surgery sub-I and remembered the anesthesiologist giving some propofol when a patient was "awake" and moving - thus the belief that it affects pain. I wanted to talk about the fact that people do respond to pain even when in drug comas, and often anesthesiologists titrate opiates and other pain relievers in based on physiological parameters, but decided it wasn't worth it.

Ultimately I found it interesting that the nature of anesthesia is so misunderstood by many people. "Give some white stuff. Pass some gas. What's so hard about that?" Apparently a helluva lot more than you'd think - since most people involved in care that mimicks anesthesia's induction and maintenance have false notions on what's going on. I don't want to know what a surgeon thinks - I'm sure it's even more basic than that.

5 comments:

Dragonfly said...

I remember an anesthetist saying to me in my 3rd year that I could be an orthopaedic surgeon easily as they know only 2 drugs, or else be an anesthetist, and have both mad skillz and knowledge. Am now inclined to agree.

T. said...

Welcome (early) to our world, MSG!

Wait till you get all the other questions like, "So, giving anesthesia for heart surgery's not the same as giving anesthesia for appendicitis?"

I have a whooooole loooooong rant about how misunderstood we are...but hey, in a way it preserves our usefulness, right? If no one else gets what we do, they have to come to us for it - whatever they imagine "it" to be!

Kellie said...

Excellent post. I had to fight for one of my patient a few shifts ago. Long term severe BPDer (trached) in a vec induced coma with highly elevated vital sign changes indicative of pain. Our neo didn't want me to give his PRN morphine even though his vitals were over 20% greater than baseline and his sats were in the upper 80s on 100% because "He already had his Valium....that should take care of it". Ummmm, no. Valium doesn't treat pain from an ulcerated trach and ascites. Thankfully the patient got his morphine, vitals went back to baseline, sats improved, and pain relief was finally given despite being on vec.

Dr. Alice said...

lol, msg, surgeons' concept of the anesthesiologists' job is basically: make the patient be quiet - however you do it.

Johnathan said...

Quite helpful piece of writing, thanks so much for this post.
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