Is propofol really that bad?

I recently had a Facebook conversation with a colleague of mine, emergency medicine registrar Matthew Oliver about post intubation sedation with propofol and I thought it was was worth sharing the main points of it.  Mat brought to my attention a side-splitting rant by critical care superhero Cliff Reid on ercast about propofol use in the resus room, and it got me thinking about my own practice regarding inducation and sedation in the critically ill.

Before I put a post together though,  I thought I’d conduct a little survey of the online critical care community to see what people are doing around the world regarding induction of anaesthesia and maintenance of sedation in critically ill patients.  So please answer the survey questions and I’ll use the results in my upcoming post on sedation in the critically ill.  The polls are only referring to sedatives.  I’m assuming that you’re using a muscle relaxant as I think that intubation facilitated by sedation borders on negligence (a post for another day perhaps).

After you’ve answered the poll, you should check out this link to the BMJ from 1944. That’s right 1944.  It gives an amazing insight into care of critically ill trauma patients during WWII.  Most of the patients died, and the authors recommended anaesthesia with cyclopropane, which I’m not sure I would.  But they do make this very insightful comment right at the end of the paper:

“The chief factors  in anaesthetizing shocked  patients seem, therefore, to be, first,  the use  of a  minimal- amount of anaesthetic – and it is often surprising  how little these patients require; secondly, the choice of an anaesthetic which stimulates rather than  depresses the cardiovascular system; and, thirdly, an  adequate amount of oxygen.”

Anyway, on to the poll. Please leave any comments below if there’s a drug that you think is missing!

Crisis. Check.

I’m a big fan of checklists, and I think they’re seriously under-utilised in medicine.  Anyone who’s had anything to do with aviation knows that pilots rely on checklists to ensure that important steps aren’t missed, regardless of whether the procedure being performed is routine (take-off, landing) or extra-ordinary  (smoke in the cockpit, double engine failure).  While anaesthetists and. as a result, surgeons have increasingly adopted checklists for routine aspects of surgery (The WHO surgical safety checklist for example) but there still seems to be a reluctance to use checklists in a crisis.  I’ve heard people say “there isn’t time for a checklist” or, even worse “I’m a specialist, I don’t need a checklist to manage a crisis.”

In my humble opinion, if a pilot has time to use a checklist while plummeting towards the ground, a doctor has time to use a checklist while dealing with a crisis that he or she may not have dealt with for years, if ever.  The main image of this post is from the Apollo 13 mission, where a series of checklists saved 3 astronaut’s lives in a situation of extreme pressure and very high cognitive loads.

Atul Gawande (@Atul_Gawande)is an American surgeon who should really need no introduction.  He is the Author of many books and essays commenting on organisation aspects of medicine, and my favourite would have to be “The Checklist Manifesto” which should be compulsory reading for all staff in critical care.

He and his team from Harvard published a neat little study today in the NEJM (Alas, subscription required) comparing performance of an operating room team in simulated crisis scenarios with and without a checklist.  The results speak for themselves.  Those teams using the checklist missed 6% of steps in the management of a complex emergency like massive haemorrhage while those without the checklist missed 23% of steps.  The full checklists are available in the supplementary appendix of the article.  As all good checklists should be, they’re simple, colourful and to the point.  Gawande’s team also have a website, where, in the spirit of FOAMed, they’re making checklists freely available and providing a forum for others to upload checklists that they have developed.

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Of course there is already an example of checklist use in a high pressure scenario that is becoming increasingly ubiquitous – thePrehospital RSI checklist that is used by HEMS the world over.  It is a simple method of ensuring that not only the right equipment is available for a common yet complex and risky procedure, but that clinicians are cognitively prepared to use rescue equipment such as the surgical airway kit.  Many HEMS physicians are now bringing the RSI checklist into their in-hospital practice, and it seems that it is being well received. Toby Fogg (@TobyF) and his colleagues from Royal North Shore Hospital ED in Sydney have developed an ED airway registry and have a great website on which the have a copy of their in-hospital RSI checklist.   Of course clinicians in prehospital care have, in a way, been using checklists for years.  Most EMS systems issue pocket sized guides to their clinical guidelines and it is common practice for paramedics and EMTs to pull them out to refer to while treating a patient.  These guides, while not checklists, are still useful aide memoirs.

Another criticism of the checklist is that if there is only one provider present (rare in-hospital, but not uncommon prehospital) then the checklist will either take too long, or be performed poorly, with steps being skipped while the clinician’s attention is divided.  Again, we can look to aviation for a potential solution.  Many single pilot aircraft have an automated checklist system which reads the steps out in a voice that sounds alarmingly like Stephen Hawking.  Now how can medicine not be improved if Stephen Hawking is your wingman?  A smartphone or tablet based automated crisis checklist could be the answer for solo providers.

Hopefully in the near future the “doctor knows best” attitude in medicine will be a thing of the past and teams caring for critically ill patients will be using checklists all the time to guide and prompt their management of both common and uncommon crises.  I’ve been working on my own set of ICU checklists for a while and I’d be keen to hear from people who have used checklists like the prehospital RSI checklist or who have developed their own crisis checklists.

Here’s the abstract of the NEJM study.
Simulation-Based Trial of Surgical-Crisis Checklists
Alexander F. Arriaga, M.D., M.P.H., Sc.D., Angela M. Bader, M.D., M.P.H., Judith M. Wong, M.D., M.P.H., Stuart R. Lipsitz, Sc.D., William R. Berry, M.D., M.P.H., M.P.A., John E. Ziewacz, M.D., M.P.H., David L. Hepner, M.D., Daniel J. Boorman, B.S., Charles N. Pozner, M.D., Douglas S. Smink, M.D., M.P.H., and Atul A. Gawande, M.D., M.P.H.
N Engl J Med 2013; 368:246-253 January 17, 2013 DOI: 10.1056/NEJMsa1204720

Operating-room crises (e.g., cardiac arrest and massive hemorrhage) are common events in large hospitals but can be rare for individual clinicians. Successful management is difficult and complex. We sought to evaluate a tool to improve adherence to evidence-based best practices during such events.

Operating-room teams from three institutions (one academic medical center and two community hospitals) participated in a series of surgical-crisis scenarios in a simulated operating room. Each team was randomly assigned to manage half the scenarios with a set of crisis checklists and the remaining scenarios from memory alone. The primary outcome measure was failure to adhere to critical processes of care. Participants were also surveyed regarding their perceptions of the usefulness and clinical relevance of the checklists.

A total of 17 operating-room teams participated in 106 simulated surgical-crisis scenarios. Failure to adhere to lifesaving processes of care was less common during simulations when checklists were available (6% of steps missed when checklists were available vs. 23% when they were unavailable, P<0.001). The results were similar in a multivariate model that accounted for clustering within teams, with adjustment for institution, scenario, and learning and fatigue effects (adjusted relative risk, 0.28; 95% confidence interval, 0.18 to 0.42; P<0.001). Every team performed better when the crisis checklists were available than when they were not. A total of 97% of the participants reported that if one of these crises occurred while they were undergoing an operation, they would want the checklist used.

In a high-fidelity simulation study, checklist use was associated with significant improvement in the management of operating-room crises. These findings suggest that checklists for use during operating-room crises have the potential to improve surgical care. (Funded by the Agency for Healthcare Research and Quality.)

Nurse! Fetch the Nikethamide and the Lobeline!

I’ve just had a most enjoyable day wasting a lot of time while watching some pretty amazing videos on youtube.  I’m a big fan of medical history, particularly the history of resuscitation and intensive care.  The Wellcome trust from UK have a cornucopia of videos available and in addition to being a fascinating look at our past, some of them are just downright hilarious.

My favourite thus far is “Respiratory and Cardiac Arrest” from 1945.  It’s aimed at junior doctors delivering general anaesthesia. Some interesting techniques include;

– Mouth to mouth in theatre

–  If trismus is present, wait until the the patient is just about dead, then force a Guedel airway in and start ventilating.

– Internal massage (from the upper abdomen) and intracardiac adrenaline routinely

And of course there are some brilliant quotes, Like;

“If an endotracheal tube is immediately available, intubate the trachea.  But don’t waste time looking for one.”

– (After ROSC) “Accompany the patient back to the ward yourself, with supplemental oxygen if it’s practicable.”

There were a couple of drugs mentioned that I hadn’t heard of:

– Nikethamide: Respiratory stimulant

– Lobeline: Sympathomimetic (increased dopamine release, decreased reuptake of dopamine and serotonin

We really have come a long way in a short time.

Among the other videos that I’ve stumbled upon there is one of what looks like one of my all time favourite moments in medical history – the MacIntosh/Pask Mae-West lifejacket tests.

To cut a long story short, during the war (I know we shouldn’t mention it), lots of airmen were dying after bailing out of their aircraft because once inflated, their life jackets would float them face down.  So the RAF turned to 2 men who, like Sir Kieth Park and Alan Turing, were great unsung (and unheard of) heroes of WWII: Grp Cpt Sir Robert MacIntosh (of Timaru, no less) and Wng Cdr Edgar Pask.  Two anaesthetists from Oxford with an interest in aviation, and war-winning.  MacIntosh of course, was the first professor of anaesthesia in the UK and is immortalized in the name of the most popular laryngoscope blade, which he developed.

MacIntosh and Pask rose the task of lifejacket development the only way that made sense – by anaesthetising Pask and throwing him in the pool while different designs were tested until one was found the would allow him to float face up.  This excellent article from the Royal Army Medical Corps Journal sums it all up nicel, as does Maltby’s excellent little book “Notable Names in Anaesthesia.” Pask got a PhD for this, which he famously joked that he was asleep for most of.  It’s unassuming, humble characters like this that make medicine such a great profession, not the Dr. Oz’s and the like of today.  I hope I can be a little like MacItosh or Pask one day.  However I don’t like the idea of being dunked in the pool while anaesthetised.  It would probably be better than HUET though….