The Star Online: Lifestyle: Health
The Star Online: Lifestyle: Health |
| Busting myths and misconceptions Posted: 06 Oct 2012 06:01 PM PDT NEARLY everyone has heard a story, or has something to tell about anaesthesia. We will attempt to bust some common myths and misconceptions about anaesthesia. Myth 1: Spinal/epidural anaesthesia causes back pain Studies have shown that there is no increase in incidence of backache after spinal/epidural anaesthesia. Myth 2: Overdose of anaesthesia This is a very commonly used term amongst non-medical people. It has been used to explain every mishap for which they cannot find a cause. There are various aspects to this. It is not proper to label all untoward incidents as "overdose of anaesthesia". This is an ambiguous statement. The drugs are given as per the dosage scheduled, and according to the condition of the patient. An international survey reveals that the incidence of mishaps in anaesthesia are 0.2%. This is a very low rate compared to other specialities, but when it does occur, it is distressing not only to the patients and their relatives, but also to the attending doctors. Myth 3: Anaesthesia is associated with inhalation of chloroform or ether In modern anaesthesia practice, chloroform has long been abandoned and ether has almost been phased out because of its side effects. These days, we have better agents than chloroform. The current practice is to use drugs that are administered into your veins to induce sleep in a peaceful manner. In smaller children, for fear of pain or injections, the anaesthesia may be induced by inhalation of newer non-chloroform inhalational agents. Myth 4: Anaesthesiologists leave the operating room once patient 'goes off to sleep' Modern practice of anaesthesia demands close and constant observation and regular updates of the situation. The surgery and anaesthesia actually go hand-in-hand, and anaesthesiologists continuously maintain the stability of the patient. The anaesthesiologist is the ever-vigilant team leader with full control of the operation theatre while surgery is in progress. Myth 5: Spinal anaesthesia causes impotence Spinal anaesthesia does not affect virility, fertility or the ability to reproduce. It does not result in impotence. Myth 6: Anaesthesiologists are technicians and paramedics It is a common misperception that anaesthesiologists are technicians or paramedics, when in fact they are extensively trained medical specialists. To become an anaesthesiologist, a doctor must successfully complete five years of a basic medical degree, an internship, and at least three years of medical officer training, before undergoing intensive training in anaesthesia for four years, after being selected through a series of examinations and interviews. A consultant anaesthesiologist will spend at least five years – after he/she is qualified as a specialist – training and taking further examinations in anaesthesia, a process overseen by the Malaysian Society of Anaesthesiologists. Myth 7: We are the 'gas' doctor We are always known as the "gas" doctor. History shows that anaesthesia is achieved with the inhalation of anaesthetic gases, and hence, the name. However, anaesthesia has advanced to greater heights, and our techniques have been substantially refined. We are not restricted to using inhalational agents, and the substances used to achieve the effect have been multiplying. Myth 8: Anaesthesia wears off before surgery if there is a dosage miscalculation There is often a misconception that anaesthetic drugs given at the beginning of a surgery are calculated to last for the expected duration of surgery without any top-up, and that miscalculations will result in the anaesthesia wearing off prior to the end of surgery. The fact is, anaesthesia will continue as long as the surgery is ongoing, either by the patient continuously inhaling anaesthetic gases, or by continuous infusion of anaesthetic drugs via the vein. This will be stopped once the surgery is completed. Myth 9: The risk of anaesthesia is less if the surgery is minor This does not happen. The risk of anaesthesia is the same even if the surgery is minor. Related Story: |
| Posted: 06 Oct 2012 06:00 PM PDT Anaesthesia is now considered one of humanity's greatest inventions, offering pain-free operations, childbirth with reduced suffering, and instant access to the world beyond consciousness. OCTOBER 16 will mark one of the path-breaking moments of science in general, and medicine in particular, as it is on this day, in the year 1846, when the first successful public demonstration of painless surgery using ether to make a patient unconscious, was performed by a dentist, Dr William Thomas Green Morton of the United States, whose grave bears the inscription "Inventor and Revealer of Inhalation Anaesthesia: Before Whom, In All Times Surgery Was Agony; By Whom, Pain In Surgery Was Averted and Annulled; Since Whom, Science Has Control Over Pain". The use of ether spread rapidly to England and other parts of the world. It was closely followed by another very popular anaesthesia, chloroform. The advent of ether marked a shift in the belief that pain is a natural part of the human experience, to the ability of medicine to control it. Imagine being strapped down, or given alcohol and other sedative drugs to ameliorate the pain of surgery, something that actually happened in the past! Surgery sans pain would have remained a fantasy, if not for anaesthesia. World Anaesthesia Day is considered the birthday of anaesthesia, commemorating Dr Morton's assistance of painless surgery. It was first observed in 1996, 150 years after this significant historic event, and is celebrated annually to mark the beginning of a specialty in medicine. In 1948, anaesthesia was recognised as a speciality of equal status with other medical and surgical specialities. Since then, anaesthesia has kept pace with the rapid advances made in surgery, and has opened a world of opportunities, enabling various life-saving operations to be performed, which would have been impossible before the help of anaesthesia. Anaesthesia has now become a highly specialised branch of medical science in today's world. Besides the historic significance of celebrating World Anaesthesia Day, this day is also a celebration of anaesthesia as a profession, and all our accomplishments. In Malaysia, this special day is an annual event jointly organised by the Malaysian Society of Anaesthesiologists (MSA); the College of Anaesthesiologists, Academy of Medicine of Malaysia; and the Department of Anaesthesiology & Intensive Care, Hospital Kuala Lumpur. Man behind the mask Anaesthesiologists are often known as the "man behind the mask". Who we are still remains very much a mystery to the majority of the public. We work within the four walls of the operation theatre. We are perceived as a less visible "form" of patient care, and a faceless partner of healthcare. Many of our patients are unaware that anaesthesiologists are medically qualified. The central aim of National Anaesthesia Day 2012 is to publicise the role of anaesthesiologists. We are involved in many areas of patient care. We are well-trained and qualified doctors who have had specialist training in anaesthesia, in the treatment of pain, in the care of very ill patients (intensive care), and in emergency care (resuscitation). Our objectives are to establish the concept of anaesthesiologists as highly specialised doctors caring for patients in all the areas of surgery, obstetrics, intensive care, and pain management. What you may like to know about anaesthesia The term anaesthesia is derived from the Greek word "an-aisthesis", which means "without feeling". It also means "loss of sensation". Not all anaesthesia makes you unconscious. There are several type of anaesthesia: general, regional, local and twilight. Millions of the population every year confidently entrust themselves to hospitals for surgery, and usually the concern is that the surgery is successful and that you don't feel anything! Well, the task of making sure that you don't feel anything is the responsibility of an anaesthesiologist. And far from just making sure you are "asleep", our job is much more complex – making sure that you are looked after before, during and after the surgery. Our role does not end with you "sleeping". We watch over you second-by-second the entire time you are in the operating room. Administering anesthesia is just one of our many responsibilities. We are not restricted to operating rooms any more. Our work is much more broad-based. About 50% of our time is spent working outside the operating theatre in other hospital departments. In fact, 90% of hospital departments use the service of anaesthesiologists, and anaesthesia is the single largest hospital speciality. We are also actively involved in 90% of the work of an acute hospital. Our out-of-operation theatre roles include: anaesthetic clinic – one of the main components of care; acute and chronic pain management in the pain clinic; obstetric and labour analgesia; intensive care in the Intensive Care Unit; interventional procedures; transfusion and blood conservation strategies; ambulatory surgery; and military surgical units and humanitarian services. The steps we follow in ensuring safety does not begin only during surgery, but commence long before that via the pre-operative assessment and optimisation of underlying problems, with careful preparation on the day of surgery. Safety is always our highest priority. Because of modern advances in technology and ongoing research, anaesthesia is 50 times safer today than what it was in the early 1980s. The extensive training and maintenance of the standards of care has made anaesthesia in this country as safe, if not safer than anywhere else in the world. Newer and safer versions of drugs with sophisticated monitoring equipment, modern applications of ultrasound-guided care, advanced anaesthetic techniques, and pain management, all make anaesthesia delivery safer than before. Modern anaesthesia is considerably safer than travelling in your car. In general, the risk of serious injury or death during anesthesia is about the same as the risk of going for a car ride. Because you are in a car almost every day, you may not consider driving particularly risky. It is extremely unusual for healthy patients to have serious complications from anaesthesia. However, a number of health problems may increase the risk of complications. One of the challenges that may hamper our practice is manpower shortage. A 2009 survey showed that there were about 620 anaesthesiologists in the country, giving us a ratio of about one anaesthesiologist to 45,000 of the population. This is still far from the figures of developed countries of one in 10,000. The prevailing ratio of anaesthesiologists to surgeons at this point in time is about one in four, as compared to one in two in developed countries. The shortage is not confined to anaesthesiologists, but also to medical officers. Surgery in a day This year, the theme of National Anaesthesia Day is "Surgery In A Day, What Do You Have To Say". This reflects our efforts to promote day-care surgery as a way forward in modern healthcare. "Isn't day-care meant for my kids?" you may ask. "How is it connected to surgery?" Day-care surgery is known by many names: ambulatory surgery, outpatient surgery, and same-day surgery. Not all surgeries performed will require you to bring a toothbrush and spend a night in the hospital. Where in the past, you may have been "out of action for days", you can now be "out of hospital" in less than 24 hours. Day-care surgery is surgery without hospital admission, and does not require an overnight stay – in essence, this means caring for you during the day. It allows you to walk in and out consciously of the operative room. Day-care surgery has undergone impressive growth in the last two decades following the development of short-acting anaesthetics, and new state-of-the-art surgical and anaesthetic techniques. In countries such as the United States and Canada, it accounts for nearly 90% of all surgeries performed. It is the global trend now. Many questions may run through your mind now. How safe is it? Does the patient experience any pain? How can the patient be sent home so fast? How about post-operative care? Day surgery provides a high-quality, safe and cost-effective approach to surgical healthcare, enjoying a high rate of patient satisfaction. Not all patients are suitable for this option. The selection of patients is a professional decision, and will vary depending on a team approach comprising of surgeons and anaesthesiologists, and based on appropriate protocols and criteria. Suitable patients Patients are carefully assessed pre-operatively after consultation by an anaesthesiologist in the anaesthetic clinic. This is to ensure that they are safely prepared for surgery, in an optimal state of health, and that the anaesthesia management is planned and related to the patients. Those chosen must essentially be healthy people undergoing minor or intermediate procedures, with good home support available in the first 12 to 24 hours after surgery. Not all surgeries can be performed as a day-care procedure. These too must be carefully selected. Suitable procedures include minimally-invasive procedures with minimal pain, nausea, vomiting and post-operative complications, with early return to normal fluid and food intake. Examples include hernia repair, laparoscopic procedures, removal of lumps and bumps, and circumcisions. Recently, patients with more complex medical problems are undergoing outpatient surgery, and the types and complexity of surgical procedures have expanded significantly. The willingness on the part of the patient to be so treated, the distance of the place of residence to the day-care centre (within one hour from the hospital), the presence of an accompanying person to provide transport (as these patients are not fit to drive after anaesthesia), and ready access to a telephone, are also considered when deciding the appropriateness for day surgery. After the surgery, discharge arrangements will include supply of appropriate pain relief medications, post-operative instructions, contact person if problems arise, and a post-operative appointment. This will be done only after ensuring that patients are stable, with adequate pain control, and minimal post-operative complications in the recovery bay after surgery. Following discharge, there may be phone follow-ups and supervision, when required. The standards of patient care in day-care surgery is the same as inpatient care, and strictly adhers to the guidelines by the College of Anaesthesiologists, Academy of Medicine Malaysia, The American Society of Anesthesiologists, and the Australian and New Zealand College of Anaesthetists minimal monitoring standards and standards of care. These monitors have significantly increased the safety of anaesthesia and surgery for all patients. Generally, complications arising after day surgery are usually minor, and mortality is extremely rare. Studies worldwide have shown that ambulatory surgery delivers the same high quality and safe care as that given to hospital patients. The key benefits of day-care procedures include faster recovery, which means earlier mobilisation; less discomfort, better healing and general outcome; less disruption and time away from family and business commitments with early return to their home environment, which translates to easier domestic arrangements; reduced risk of cross infection in hospitals; and less time away from work and normal activities, which is equivalent to less loss of pay. Patients can recuperate where they are most comfortable – in their own homes, as there is little need for close professional nursing care after surgery. There is also less anxiety among patients, especially children, with separation for as short a time as possible from their parents; and the elderly, who are more prone to disorientation when removed from their familiar surroundings for extended periods of time. From the hospital point of view, there is improved surgery scheduling, reduction in staff and hospital costs, and a consequent decrease in waiting lists. All these translate to economic advantages, not only to the patients, but also the healthcare facility. Promoting day-care Day-care surgery should be the byword now, and we are looking forward to higher acceptance of this modality in our country. This win-win situation for healthcare facilities, as well as patients can be accomplished – all in a day's work. It is heartening to observe that day surgery is becoming increasingly popular. In our country, there are eight centres with such facilities: Selayang, Klang, Putrajaya, Ipoh, Kuantan, Penang, Alor Setar and Kuala Terengganu. Hospital Kuala Lumpur is expecting its very own ambulatory care centre very soon. Let's breach the barriers and march towards a new frontier, and make day care surgery happen nationally in our country. This year's celebration is being organised as a national event this coming Saturday, with the collaboration of both the government and the private sector in the form of a telematch event in Hospital Kuala Lumpur. We take this opportunity to invite you to actively participate in this event. Come visit us at Hospital Kuala Lumpur on Oct 13 and join our telematch, and we will be happy to address any of your enquiries or doubts. > Datin Dr V. Sivasakthi is president of the Malaysian Society of Anaesthesiologists and head of the Department of Anaesthesiology & Intensive Care, Hospital Kuala Lumpur; Assoc Prof Datin Dr Norsidah Abdul Manap is president of the College of Anaesthesiologists, Academy of Medicine Malaysia. Related Story: |
| Posted: 06 Oct 2012 05:55 PM PDT The likelihood of blood clots forming in veins – venous thromboembolism – increases in pregnancy. BLOOD travels from the heart to the rest of the body through blood vessels called arteries, and returns back to the heart through other blood vessels called veins. Veins are either superficial or deep. The former are close to the surface of the body, and the latter are deep in the body and are almost always beside an artery of the same name, eg the iliac vein is adjacent to the iliac artery. Arteries and veins are structurally different. The former have muscular walls, unlike the latter, which also contain valves. Blood clots can form in an artery or a vein (thrombosis). Arterial thrombosis leads to a compromise of the blood flow to the body part served by the artery. The term venous thromboembolism (VTE) is used to refer to thrombosis in veins. VTE can occur in any vein in the body. The common sites are the veins in the legs and/or pelvis (leading to deep vein thrombosis – DVT) and the lungs (leading to a pulmonary embolism – PE). The most serious complication of a DVT is PE, which is life-threatening. PE results from a thrombus breaking off (embolising) and travelling to the lungs where it can get stuck, leading to a compromise in the blood flow to the affected part of the lungs. The likelihood of DVT is increased during pregnancy, and in the first six weeks after childbirth. The risk is one in 500, which is 10 times the risk of a non-pregnant woman of the same age. The highest risk of DVT and/or PE is in the immediate period after childbirth. However, it is important to remember that DVT and/or PE can occur at any time during pregnancy, even in the first three months. About 10 to 20% of VTEs are PEs, which is a common cause of maternal deaths in developed and developing countries, including Malaysia. Defining risk factors There are several risk factors, some of which are inherited, while others are acquired. These risk factors are identifiable in about 80% of those affected. It is not uncommon for a person to have more than one risk factor. The inherited risk factors include Factor V Leiden mutation, Prothrombin gene G20210A mutation, Antithrombin III deficiency, Protein C or S deficiency, disorders of plasminogen and plasminogen activation, and a strong family history (mother, father, brother or sister who has had a DVT). The acquired risk factors include obesity (body mass index, BMI, of 30 kg/m² or more), smoking, intravenous drug usage, immobilisation (more than four days of bed rest), previous thrombosis, trauma, cancer, infections, nephrotic syndrome, cerebrovascular event, severe varicose veins, especially if they are painful, and long-haul travel of four hours or more. The risk factors related to pregnancy are maternal age of 35 years or more, multiparity (have had three or more babies), previous DVT, high blood pressure, dehydration, medical conditions like heart disease, lung disease or arthritis, multiple pregnancy (twins or more), and hospitalisation. The risk factors related to delivery are prolonged labour, instrumental vaginal delivery, Caesarean section, post-partum haemorrhage, and blood transfusion. The risk of VTE may increase or decrease. It may increase if other factors develop in addition to the initial risk factors, eg complications during delivery in an obese mother. It may decrease with smoking cessation. The obstetrician and the midwife will assess a pregnant woman's risk at the time of pregnancy, when changes occur during pregnancy, at admission to hospital, and after delivery. The clinical features of DVT and PE are the same as that of the non-pregnant. The features of DVT include discomfort and/or pain in the legs, swelling, tenderness, warmth, and an increased white blood cell count. There may be abdominal pain. Some of these symptoms are non-specific as they are also found in normal pregnancies. There may be no symptoms in about 50% of those with DVT. The features of PE include sudden unexplained difficulty in breathing, tightness in the chest or chest pain, coughing up blood (haemoptysis), and collapse. There may be no symptoms in some patients. Diagnosis and treatment DVT is diagnosed clinically and with an ultrasound scan of the leg. If there is no sign of thrombosis but the symptoms persist, a repeat ultrasound is usually done. PE is diagnosed with a chest X-ray, a CT scan of the lungs, and/or a ventilation perfusion (VQ) scan of the lungs. The amount of radiation in a chest X-ray is very small. If it is done during pregnancy, the foetus will be protected with a shield. There are small radiation risks from CT and VQ scans, which have to be balanced with the risks to the mother and foetus of an undiagnosed PE. The risk of developing childhood cancer from a CT scan is less than one in 1,000,000, and one in 280,000 with a VQ scan. However, the radiation dose to the breast from a CT scan is more than that of a VQ scan, which may increase the lifetime risk of breast cancer. After a diagnosis of DVT has been made, the patient will be prescribed an anticoagulant called heparin to "thin the blood". The heparin prevents the thrombus from increasing in size so that it can dissolve gradually, reducing the risk of the development of another thrombus, thus reducing the risk of PE. There are different types of heparin, with "low molecular weight heparin" (LMWH) commonly prescribed in pregnancy. It is given as an injection underneath the skin (subcutaneous) at the same time every day, and sometimes, twice daily. The dose is adjusted according to body weight. Patients will be taught how and where to inject themselves, just like diabetics with insulin injections. Hospitalisation is usually not required with most mothers managed as out-patients. The heparin has to be injected for the rest of the pregnancy. LMWH does not harm the foetus because it does not cross the placenta. There may be some bruising at the injection site, which usually fades away within a few days. An allergic reaction may occur in one to two in every 100 women. If there is a rash after the injection, the doctor should be informed, and the type of heparin changed. Heparin has to be stopped when labour is suspected to have started. It is stopped 24 hours before induction of labour or planned Caesarean section. Epidural analgesia or anaesthesia cannot be given until 24 hours after the last heparin injection. An alternative mode of pain relief will be recommended. Heparin will usually be recommenced about four hours after a planned Caesarean section. If an unplanned (emergency) Caesarean section is indicated within 24 hours of the last heparin injection, it will be done under general anaesthesia, and not epidural or spinal anaesthesia. Anticoagulants will be prescribed for at least six weeks after childbirth. The choices of continuation of heparin injections or warfarin tablets should be discussed with the obstetrician. Both heparin and warfarin can be taken by breastfeeding mothers. Warfarin is not prescribed in pregnancy as it can harm the foetus. So, a pregnant mother on warfarin would be advised to stop it and take heparin instead. Other therapeutic measures in DVT include staying as active as possible, use of graduated elastic compression stockings, and medicines for pain relief. PE requires hospitalisation and is managed as an emergency. Medicines that dissolve the clot (thrombolytics) and prevent the formation of more clots (anticoagulants) are prescribed. Support measures like ventilator, medicines for the heart, etc, may be necessary in life-threatening PE. Surgery is sometimes needed for patients at great risk for another PE. At the post-natal visit, the obstetrician will elucidate any family history of thrombosis and discuss investigations, contraceptive options, the management of future pregnancies, and advise on the use of a graduated elastic compression stocking on the affected leg for two years. Preventing clots VTE can be prevented by measures that include staying as active as possible, smoking cessation, maintenance of hydration by drinking adequate amounts of fluids, wearing graduated elastic compression stockings, and weight reduction prior to getting pregnant, if overweight. Pregnant women who have certain risk factors, eg previous DVT, would also be prescribed prophylactic heparin. n Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information. |
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