Did you realize that 20% of Americans still smoke? That is an amazing number considering that cigarette smoke has some 6000 identifiable constituents! Some of the constituents include: ammonia, arsenic, benzene, formaldehyde, toluene, and vinyl chloride. I don’t know about you, but that sounds appetizing! But what does this mean for the anesthetist working in the clinical setting? For starters, smoking increases the likeliness of an irritable airway and a greater potential for hypoxia. There are a few steps you can take to try and mitigate the effects smoking can bring to the table. A thorough pulmonary examination is a great start. Listen to the lungs and ask if there is a history of wheezing, coughing, and expectoration. Observe their passive breathing and note if there is clubbing of the nails. Are they short of breath just sitting in the pre-op area? This can be an indication of pulmonary disease and prompt the need for further evaluation. As a side note, if they have pulmonary disease it is very likely that they cardio-vascular disease as well. While doing your H&P, don’t hesitate to focus on this area as well. Next, take a look at the medications they are on. If they use inhalers, ask them about the last time they used them and how frequently they use them. This is another good indicator for potential problems during the procedure. Have them use their inhaler before the procedure. It never hurts to have the airways as open as possible prior to a procedure. Chuck Biddle, CRNA, has a great list of considerations for the smoker that include, abstinence for 24 hours if possible, bronchodilators, nicotine patch if possible, pre-oxygenate, and there may be a need for increased analgesia during the procedure. Also be aware that their FRC (functional residual capacity) may be diminished. This may lead to a state of hypoxia sooner than normally expected in a non-smoker. Be prepared! And finally, as anesthesia providers we have a unique opportunity to educate our patients about the deleterious effects of smoking. For a brief period of time the patient is a captive audience, don’t hesitate to seize this opportunity for education.
A recent article brought about some very important and simple symptoms that patients can use to evaluate their susceptibility to sleep apnea. In an article by Dr. Orly Avitzur M.D., she describes the need for medical evaluation of loud snoring. She stated up to 1 in 10 women and 1 in 4 men might have undiagnosed sleep apnea and the first symptom to look at is loud snoring . She further states that less than 15% know they have sleep apnea and most physicians don’t routinely inquire about it during office visits. Other symptoms that warrant further professional evaluation include, but are not limited to: High blood pressure Frequent morning headaches Day time drowsiness Frequent wake-ups Frequent morning sore throats Wake-ups with choking or gasping for breath Wake-ups in a sweat Overweight Loud snoring Sleep apnea increases a persons chance of high blood pressure , stroke and type 2 diabetes, but the most terrifying statistic Dr. Avitzur stated is there is an increased risk of death that is associated with having sleep apnea. Anesthesia providers especially need to be aware of any of the symptoms listed above prior to administration of any anesthetic, so please inform them before any surgery. Additional protocols may be implemented in the pre and post-op areas and drug regimes may be modified if the symptoms are present in a patient. Avoid anesthesia complications with sleep apnea by speaking with your physician. Check out this article on sleep apnea and same-day surgery for more information. As sleep apnea affects such a high number of people, we would appreciate any personal experiences with sleep apnea you could share on this blog.
The adverse events rate is low when Propofol is administered by a trained professional such as a CRNA. In a recent article published in Clinical Gastroenterology and Hepatology, a study was performed with patients undergoing a variety of endoscopic procedures with sedative dosing administered by a CRNA. This article stated, “… this is the first paper to report the frequency of airway modification associated with the use of propofol in endoscopy.” The article continued to highlight the importance and need for trained personnel, such as CRNA’s, to monitor patients during sedation with propofol. The conclusion by Sreenivasa Jonnalagadda M.D., the lead author of the article, confirmed ” … Highest-risk patients should be managed by nurse anesthetists trained in advanced airway interventions…” . For further reference and information please see the April 2010 Clinical Gastroenterology and Hepatology Journal.
Centers for Medicare and Medicaid Services (CMS) issued a statement that it no longer requires physician supervision of CRNA’s providing labor analgesia or moderate sedation in hospitals participating in Medicare. Along with this announcement was an additional statement that Medicare requires, during deep sedation with propofol, the involvement of an anesthesia provider such as a CRNA. This revision was to “ensure high quality, safe, and effective care provided by CRNA’s throughout the United States” as stated by James Walker president of AANA. In the article from the January AANA Journal, specific reference is made to the example of “deep sedation” for colonoscopy screening. It goes on to state most propofol use in this area is used to decrease patient movement and improve visualization in this invasive procedure. It continues, the reason that anesthesia personnel are needed is the potential for inadvertent progression to general anesthesia. Thus, the need for a highly qualified individual trained in anesthesia is a must. You can read more through the AANA website here, but you must register first. Additional resources on this topic can be found below: America Society of Anesthesiologists – Revised Interpretive guidelines Outpatient Surgery Magazine – CMS Substantially Alters Guidelines for Hospital Anesthesia Services Medical Society of Virginia – CMS revises interpretive guidelines for anesthesia services in hospitals The Health Law Partners – Anesthesia Guidelines Clarified: CMS Issues Transmittal on May 21, 2010
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