Gabriel M. Gurman
I chose my profession many years ago almost by chance, but I feel that my decision was the right one. I have practiced anaesthesia and critical care on three continents in five countries. In every single circumstance I found my colleagues performing their daily activity with dedication, professionalism, and humane approach.
In spite of the not so seldom heard opinion about the weak relation between the anaesthesiologist and his/her patient, the reality is completely different. We do not differ too much from other medical specialties.
Today we do not meet our patient, for the first time, in the operating room. The anaesthesia outpatient clinic is the place where the patient encounters the anaesthesiologist days and weeks before surgery. The pain clinics, very often led by anaesthesiologists, create a strong and continuous link between the suffering patient and his/her physicians. Finally, the intensive care units represent a place where the relation between the doctor and the patient and families is one of the strongest in the medical field.
But what makes me especially proud of being an anaesthesiologist is the high quality of the care we offer to our patients. One has only to look to the tremendous decrease in the rate of incidents, accidents, and mortality in the operating room in the last decades to reach the conclusion that our profession, practiced with dedication, enthusiasm, and especially with special attention to the patient’s safety and wellbeing, is one which has to be admired by everybody, peers and laymen.
I selected the theme of this editorial after getting information about a tragic case which, even indirectly, indicates the crucial role an anaesthesiologist could have in order to protect a patient’s life.
Here are, briefly, the details. A 60-year-old patient, suffering from morbid obesity (BMI 43), chronic obstructive lung disease, and obstructive sleep apnoea complained of changes in her digestive behaviour, postprandial abdominal pain, and fatigue. Her family doctor indicated the need for a gastroscopy and colonoscopy to be performed in a gastroenterology (GE) outpatient clinic. The pre-procedure investigations included usual blood tests and an EKG, all normal.
The patient was accepted at the clinic by a gastroenterologist, who explained to her about the procedure, to be done under sedation, administered by the gastroenterologist himself and his nurse aide, as is usual in many countries and many places.
Neither the family physician nor the GE specialist gave any attention to the significant co-morbidity the patient suffered from. She was put on the procedure table, a pharyngeal local anaesthesia was provided by cocaine spray, and then midazolam and propofol were administered intra-venous.
Shortly after termination of the gastroscopy, when the sedation level had to be deepened in order to permit the start of the colonoscopy, the patient suddenly developed respiratory arrest, with a quick oxygen desaturation. Tracheal intubation failed, as well as attempts to use mask ventilation. Cardiac arrest followed and death was declared by the ambulance staff, called to help.
During the last three years of my clinical activities I was assigned, once a week, to provide sedation for GE. The patient whom I just described is typical for many cases I was supposed to take care of. She could be easily included in the ASA category III, which definition is:
Substantive functional limitations; one or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents.1
A study done on a paediatric population2 clearly indicated that respiratory events during sedation for endoscopy have been noted especially in patients with ASA II or higher. The practical conclusion is clear. That specific patient had to be treated in a special setup, which would include the full participation of an anaesthesiologist. He/she would perform a full physical examination, including the accessibility of airways in case of a need for an instrumental management. The patient would have been sent to a pulmonary functions laboratory and her respiratory abilities and reserves fully evaluated.
Once the procedure had to be performed, the anaesthesiologist would have taken all the necessary measures to prevent a complication. The set for managing difficult/impossible tracheal intubation would have been prepared far in advance. Besides the usual instrumental monitoring, due to the patient’s serious pulmonary co-morbidity, one should have added a capnograph for early detection of CO2 retention.
I am fully aware of the fact that all over the world there is a perennial shortage of anaesthesia manpower. We are witnessing a tremendous increase in the need for an anaesthesiologist’s presence in almost every corner of a hospital or ambulatory setup. No country can cover this demand. This is the reason why some of the tasks that normally need to be performed by an anaesthesiologist are transferred, volens nolens, to other professions (GE specialists, radiologists, paediatric specialists, etc.) and even to nurses.3 This kind of decision led to a situation in which nonanaesthesiologists are permitted to use anaesthetic drugs that could, in some cases, jeopardize the cardiorespiratory stability of the patient.
One cannot ignore the trend in some studies to prove that using non-anaesthesiologists for nonoperative sedation could be beneficial from the economic point of view. Hassan, in a recent study, concludes:
The absolute economic benefit of EDP (endoscopist direct administration of propofol) implementation in a screening setting is probably substantial with 10-year savings of $3.2 billion in the US and €0.8 billion in France. The impact of an eventual EDP-related mortality on EDP cost-effectiveness seems marginal.4
In many places in the world the non-anaesthesiologists are supposed to pass a theoretical course in order to accumulate knowledge regarding the use of anaesthetic drugs for their patients, but nobody could offer them the experience and expertise that every certified specialist in anaesthesiology has after so many years of daily activity in the operating room and outside it.
The solution, at least a temporary one, is a very strict selection of the patients who are supposed to get sedation performed by non-anaesthesiologists. A recent paper5 concluded that non-anaesthesiologist administration of propofol for GE procedures “can be considered safe for low-risk patients (ASA class I and II). The presence of a trained anaesthetist is advisable in high-risk patients (ASA III and higher) with significant co-morbidities.”
Another paper6 stipulates that in their study of sedation performed by a non-anaesthesiologist “exclusion criteria were inability to provide informed consent, history of allergic reactions or hypersensitivities to midazolam, propofol, eggs, or soybeans, high-risk head and neck anatomy (Mallampati score > 2) that could complicate airway rescue, sleep apnoea syndrome, ASA class > II.”
But clinical judgment cannot be inherited genetically and this is why mistakes in this domain could easily lead to catastrophes.
The anaesthesiologists’ task is crystal clear. First of all, we are supposed to offer as much help as our manpower capabilities permit in each medical institution. It is our obligation to cover as much as possible the need for providing anaesthesia and sedation, cleverly using the ability of each staff member. But, as mentioned above, it would be impossible to cover all the current needs. So, our second task is to prepare, theoretically and practically, all those who are supposed to be involved in the loop of management of patients who need sedation.
In the case briefly described above, the first hole of the “Swiss cheese” principle was the family physician. He was supposed to stop the logical process that led to the tragic outcome. This is why family physicians, paediatricians, and general practitioners are to be included in the groups who would receive instructions regarding preparation of the problematic patient for procedures needing sedation. More than this, it is compulsory to pass to those clinicians the list of criteria for selecting the patients to be directly sent to a clinic that cannot provide an anaesthesiologist’s service.
The medical administration in every facility is obliged to understand the simple fact that the anaesthesiologist’s tasks include not only administration of anaesthesia, but also leading an efficient and continuous program of educating colleagues from other specialties regarding the limited professional capabilities of nonanaesthesiologists involved in administration of sedation. Theoretical courses are not enough. Exposure, even for a short time, to practical activity is essential to understand the limits of physicians who are not anaesthesiologists in dealing with techniques that could become, “out of the blue”, dangerous for the patient.
One of the most known anaesthesiologists of the mid-twentieth century proclaimed many years ago7 that we are those who better understand the homeostasis in the operating room, since the anaesthesiologist is the real “professional gas exchanger”.
Today we know that this is a truism. We are those who understand better than others what happens to the surgical patient from the cardiovascular and respiratory point of view. We are those who are able to prevent catastrophes in the operating room and not only there. This is the origin of our legitimate proudness.
Needless to say, all the above represent the author’s own opinions. He does hope that this editorial will be followed by comments coming from our readers and members.
- American Society of Anesthesiologists. ASA physical status classification system. https://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system
- Caperrel K, Pitetti R. Pediatr Emerg Care 2009;10:661-4.
- Rex DK, Heuss LT, Walker JA, Qi R. Gastroenterology 2005;129:1384-91.
- Hassan C, Rex DK, Cooper GS, Benamouzig R. Endoscopy 2012;44:456-64.
- Khan HA, Umar M, Tul-Bushra H, et al. Arab J Gastroenterol 2014;15:32-5.
- Repici A, Pagano N, Hassan C, et al. World J Gastroenterol 2011;17:3818-23.
- West JB. Anesth Analg 1975;54:409-18.