Tuesday, July 29, 2014

Are You Getting the Right Anesthetic?

When you're about to have surgery, the last thing you want to worry about is the efficacy of the drugs used to put you under. But with an acute shortage of anesthesia drugs, this is a real concern in the medical field.
According to a survey by the American Society of Anesthesiologists, 98 percent of anesthesiologists in the U.S. experienced a drug shortage in 2012. The causes, says Jeff Jacobs, an anesthesiologist in Fort Lauderdale, Florida and chair of the committee on ethics for the ASA, “are myriad.” Some drugs require raw materials from developing countries – say in Africa – where there might be a civil war. Many manufacturing plants in the U.S. are dated and have limited capacity. A lot of the drugs are also generics, so pharmaceutical companies are not incentivized to produce more of them, compared to high-cost specialty drugs.
These factors have created a stressful scenario for anesthesiologists. “We’ve come very close at times [to canceling surgery], but being a big system, we can borrow from other facilities,” says Chris Snyder, the drug information pharmacist who oversees shortages and recalls for Cleveland Clinic in Ohio.
Alternative Drugs
The vast majority – some 96.3 percent of doctors surveyed by the ASA – end up using alternative drugs, which may have different side effects than the routine drugs, or they import the same drugs from other manufacturers, often overseas, which may have different side effects.
David Rosen, an anesthesiologist in Chicago and president of the Midwest Anesthesiology Partners, recalls a new anesthetic used on elderly patients undergoing electroconvulsive therapy that turned out to be five times as strong as the routine drug. “We were having patients with really low blood pressure after the procedure, or they were not waking up after 45 minutes,” Rosen says. “We were lucky there was no harm done, but we were close.”
One of the most common anesthetics – propofol – became well-known when Michael Jackson died after taking a large dose of it. For many doctors, propofol is the induction drug of choice, used to sedate patients before other anesthetics are given. Manufacturing delays have caused shortages of propofol, forcing doctors to find alternatives.
“The beauty of anesthesia … it’s like a soup or a stew … there are lots of different things in it,” Rosen explains. “Just because I am out of propofol doesn’t mean I can’t take good care of you.” But if he’s out of toradol, a commonly used painkiller, “that’s when I’m adjusting more than I want to,” he adds. Generally speaking, to make up for a shortage of anesthetics, doctors end up using more narcotics, which can cause nausea and delayed awakenings.
Talk to Your Anesthesiologist
So what does all this mean for you? Anesthesiologists, much like pathologists, are sort of behind-the-scenes doctors with whom patients normally have limited contact, apart from five minutes before surgery, when patients are often too anxious to ask questions or hear answers. So put in a phone call to your anesthesiologist a few weeks before your procedure, Rosen says. “I like that people Google their procedure beforehand – it’s a good basis for asking more intelligent questions. But the best way is to ask questions of the people taking care of you.”
The first question to ask, he adds, is who is actually going to be taking care of you: an anesthesiologist, a nurse anesthetist (who, in 85 percent of cases nowadays, will administer drugs), a resident or the surgeon. Plastic surgeons, for example, often administer anesthetics for their own procedures, Rosen says.
Sometimes, sub-specialists are also involved, like pediatric anesthesiologists if children are being operated on, or those who specialize in pregnant women or the elderly.
“It’s definitely appropriate [for patients] to ask if any drugs are unavailable at this time, and how it affects what [doctors] are doing,” Rosen says. “Hopefully this will give patients some sense of confidence and put more pressure on the hospital administration that this is a huge problem we’ve been facing for many years.”
Rosen adds that a little bit of patient pressure could go a long way, too, because hospitals are increasingly concerned about patient satisfaction as well as safety issues – and sometimes last-minute drug substitutions can pose real safety concerns. “From an ethical point of view, if with a certain [alternative] anesthetic, increased morbidity or mortality really exists, then you have an obligation to discuss that with patients,” Jacobs says. And if patients are prone to potentially suffering adverse side effects [if they have a history of motion sickness, for example], then you may want to consider rescheduling surgery, he adds.

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