All’s Not Well in La-La-Land

mtm3njq0odu1mjc3otixntiyWhat’s the #1 thing that patients worry about most when you talk to them about anesthesia?  Is it the IV’s and endotracheal tubes…maybe aspiration or bleeding…not waking up from anesthesia?  Nope.  Believe it or not, in my almost 20 years of doing anesthesia, the most pressing request I get from patients is to make sure they’re asleep before the Foley bladder catheter gets put in…no joke.  But that’s not necessarily anesthesia-related, so we can explore that one at another juncture.  Setting aside the usual concerns of losing bowel and bladder function (because that happens all the time when people are awake and actually happens less commonly under anesthesia), the most common anesthesia-related concerns that patients express go something like this:

“Am I going to be asleep for the whole surgery?  I’m not going to wake up in the middle of surgery or anything, am I???”

And who can really blame the them, right?  Everyone’s got a mother or a cousin or an uncle or great-grandparent that woke up in the middle of surgery…just like in the movies.  In fact, according to Wikipedia there are no fewer than 5 major motion picture films and 2 television series episodes centered around awareness under anesthesia – all since the year 2005!  And in the time since I did my anesthesia training up until today when I was doing cases with a new student anesthesia nurse, the first admonition that the teacher always gives the student is this:

“You better make sure you give the patient enough {gas, propofol, narcotic, etc} so that he doesn’t wake up!”

So thankfully it appears that the interests, intents, and fears of patients and anesthesia professionals are perfectly aligned, and all is well in the land of anesthesia…

Or is it???

niaa_00342_xlIt’s interesting to me that there is such a public concern and backlash about awareness under anesthesia.  I’m not saying that it’s unwarranted by any means, but the amount of anecdotal reporting dramatically outpaces the actual incidence of unintended awareness under anesthesia.  The latest mega-study on awareness has significantly downplayed the risk of unintended awareness under anesthesia to be 1 in 19000 general anesthetics…much less than the previous estimates, which were as high as 1 in 600  That’s comforting.  But how have we gotten this number down so dramatically?  You would think that a study that didn’t depend on patients self-reporting awareness and instead asked patients detailed and pointed questions about what they remember…well…you’d think the numbers for incidence would be sky high….and yet it was the complete opposite.  So again, how did we do it?

The answer:  Midazolam

The fact of the matter is that we anesthesia folks…in addition to loving volatile anesthetics, opioids, hypnotics – if all else fails in our armamentarium – we love our amnestics, our benzos…WE LOVE VERSED!  Mostly anyway.  And is it any wonder why?  It’s potent and short-acting.  It’s water-soluble so you can give it intravenously, orally, down the nose, up the butt.  You can cheek it, and heck you could probably squirt it in someone’s eyes and that person would be happy as a clam in time.  And it’s dirt cheap…so cheap in fact that in 2011, the WHO added midazolam to its Model List of Essential Medicines, the most important medications needed in a basic health system.  And it’s basically a Versed lovefest for us anesthesia folks because our patients get all relaxed by its anxiolytic properties and are unable to form memories of the stressful perioperative period due to its anterograde amnestic properties.  We tell patients that we’re going to send them on an all-expenses-paid trip to La-La-Land and they get this big smile on their faces, and everything is groovy…Right???

WRONG, apparently.

We know enough about midazolam now that we don’t give it to pregnant women during the first trimester.  It is also sequestered in breastmilk  and causes neonatal withdrawal syndrome and apnea, which should sound universally bad to you. In fact, if you give anyone midazolam on a regular basis or in a large enough dose, you can elicit a pretty predictable tolerance, dependence, and withdrawal profile.  And don’t even get me started about giving it to old people.  About the only surprising development in the world of midazolam is that it has replaced thiopental in the First World for lethal injection in the capital punishment penal system.  Go Versed!

So…don’t get me wrong.  I am an anesthesiologist, and I love Versed.  I mean, I really love Versed.  But what tempers my love to the greatest extent is what patients say once they’ve recovered from midazolam.  They look great when the anxiolysis hits, and our own stress level decreases as well.  No matter what happens, midazolam will be on our side and the patient will be less likely to remember anything associated with our vigilance or lack thereof.  But even though patients may say they don’t want to remember anything, the actual feeling of not remembering afterwards is very distressing.  I’m not saying that this dissatisfaction rises to the level that every patient voices their complaint, but one only has to review some of the stories on “No Midazolam” or “VersedBusters” to realize that it is out there.  And though it may be an insignificant sliver of patients who complain loudly about their experience of being duped or coerced into taking this trip to La-La-Land, we as anesthesia professionals need to resist the temptation to ignore this minority and really examine why we do what we do.  Afterall, the perennial thought is that good bedside manner is worth as much Versed as you would ever want to give.

Do unto others…

To wrap it up and get off my soapbox, I’ll summarize my interpretation (i.e. my opinion)…Awareness under anesthesia remains a rare occurrence that neither patient nor provider would wish on one another.  We as anesthesiologists have stacked the deck against this exceedingly rare possibility by over-administering midazolam.  No doubt, we are erasing the problem of awareness from our minds and the minds of our patients.  But in exchange, we are forgetting that the right to remain aware and in control is as important for our patients as it is for ourselves.  Perhaps, at the very least, we should be more realistic in describing La-La-Land to our patients, and let them decide whether to take that trip or not.

Hopefully you’ve enjoyed this discussion.  If so, leave me a comment.  If not, leave me a comment!  But if I’ve caused you to think twice the next time you draw up Versed into a syringe, then I’ll consider it mission accomplished.  Really, this all boils down to that little thing called the Law of Reciprocity (aka. The Golden Rule) all of us learned in kindergarten…We’re all just human beings put on this Earth to take care of one another.  So go forth, anesthetize, and above all else…”do unto others…”

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3 thoughts on “All’s Not Well in La-La-Land

  1. CRNA here…found that avoiding versed in the more elderly (>60 yo) resulted in quicker, more crisp wake ups, faster discharges from PACU. Changed my practice after 19 years. Used it all the time on everyone before I changed. Then came the patient satisfaction surveys that the hospitals were falling all over themselves about. Even has my picture to remind the patient of who I am. Hospital pays people to call and harass patients about filling out the survey to track what kind of anesthetist I am. Since I began avoiding versed in a very large segment of my patients, guess what? My patient satisfaction scores fell and I lose bonus $$$. It’s about BS stuff like “I wasn’t warned about how cold the OR was going to be and it was upsetting”.

    Everyone gets versed now, and I get my bonuses.

    Liked by 1 person

    • I know exactly how you feel, as I have experienced the same. So much of what we do now is customer care. I used to be able to wheel my pts into the OR and immediately put them to sleep. Now I have to call the surgeon, wait for the surgeon to arrive, and then do the HRST timeout…all before I can do what the pt expects me to do. So the pt spends maybe 10-15 minutes laying there awake wondering WTH is going on. It does get reflected in the saitisfaction scores, I know. So versed comes back into play perhaps. It’s a bit of a double-edged sword…damned if you do, damned if you don’t. But it’s still useful to keep a perspective…we’re just trying to balance things for the pt…with the caveat that every patient is different. Thanks for your very thoughtful comment, Chardin, and for continuing to visit us here!

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