AN ANESTHESIOLOGIST CAN SAVE YOUR LIFE WITH ONE FINGER

Author: Richard Novak, MD

THE ANESTHESIA CONSULTANT

Consider this:

• A surgeon can save the life of a hemorrhaging patient by placing one finger over a bleeding artery, followed by suturing the hole in the blood vessel.
• An internal medicine doctor can save a life by inserting his or her index finger into a male patient’s rectum and feeling an early stage of a what may be a prostatic cancer mass.
• An anesthesiologist can save your life by treating airway obstruction with as little as one finger, thereby maintaining safe oxygen flow in and out of your lungs.

Patients wonder what their anesthesiologist is doing while they are sleeping. Let’s look at a common anesthetic technique for simple surgical procedures—an intravenous infusion of the sedative anesthetic propofol. This is a common technique for short procedures such as a colonoscopy, an upper gastrointestinal endoscopy, or the retrieval of an oocyte (unfertilized egg) from a woman’s ovaries. For these brief propofol infusion anesthetics, an airway tube is almost never used. Anesthesiologists supply oxygen via a mask or via a nasal cannula. Required infusion rates of propofol may vary during the procedure. The more propofol the anesthesiologist administers, the deeper the level of the drug-induced coma.

At deeper levels of propofol concentration, patients begin to have more respiratory depression, marked by smaller volumes moving in and out with each respiratory effort, and relaxation of the soft tissues in the throat that surround the upper airway. At deeper levels of propofol concentration, some patients have total obstruction of their upper airway, either because the tongue drops posteriorly into the airway, or because soft tissues collapse toward the midline. Either of these will stop the movement of oxygen into and out of the windpipe. This is essentially a pharmacologically induced form of obstructive sleep apnea. During sustained airway obstruction, without the intervention of the anesthesiologist, a patient’s oxygen saturation (as measuring by the pulse oximeter on the patient’s finger) will begin to drop.  An oxygen saturation less that 90% is unsafe and requires immediate intervention by the anesthesiologist.

In any anesthetized patient or critically ill patient, acute resuscitation always follows the pneumonic A-B-C, for Airway-Breathing-Circulation. Anesthesiologists are experts in airway management. For patients without an airway tube, we utilize the simple but elegant measures of a jaw thrust or a chin lift.

Jaw thrust is performed by placing the index finger of each hand on the right and left angles of the mandible (the jawbone) and pulling the jawbone aggressively upward toward the ceiling. This maneuver lifts the tongue away from the posterior airway and reopens the throat passage to remedy the obstruction. The oxygen saturation will usually begin to rise toward its initial level of 100% once again.

 

Chin lift is an airway maneuver which requires no more than one finger to open the airway. When the airway of a spontaneously breathing patient becomes obstructed, the anesthesiologist places one index finger under the patient’s chin and then pulls the chin upward toward the ceiling. This opens the airway by both pulling the jawbone anteriorly (similar to the jaw thrust) and stretching the patient’s neck into extension. Note that both the jaw thrust and the chin lift are taught in Basic Life Support (BLS) classes as potential remedies to improve the breathing of an unconscious (non-anesthetized) person.

After an anesthesiologist improves the airway via a jaw thrust or a chin lift, he or she may move further to improve the obstructed airway by:

• decreasing the anesthetic depth, or
• maintaining an ongoing jaw thrust or chin lift, or
• inserting an oral airway
  

  ORAL AIRWAY

  or nasal airway

   

  

  NASAL AIRWAY

• placing a mask over the patient’s face and performing bag-mask ventilation, or
• inserting an airway tube (Laryngeal Mask Airway or endotracheal tube if necessary.

 

Michael Jackson’s Death

In all probability, Michael Jackson died of upper airway obstruction. He was receiving propofol without an anesthesia professional to monitor his airway, breathing, and oxygen saturation. Untreated total airway obstruction can lead to plummeting blood oxygen levels in minutes. Irreversible hypoxic brain damage can occur if there is a lack of oxygen to the brain for as little as 5 minutes. The package insert for propofol states: “For general anesthesia or monitored anesthesia care (MAC) sedation, propofol should be administered only by persons trained in the administration of general anesthesia.” The administration of propofol by a physician not trained in general anesthesia, in the setting of Michael Jackson’s bedroom, and without supplemental oxygen administration, was deadly. Had an anesthesiologist been present when airway obstruction occurred, a jaw thrust and/or a chin lift would have, more likely than not, prevented his low oxygen levels and his death.

How often does an anesthesiologist resort to using a jaw thrust or a chin lift? When doing a propofol anesthetic without an airway tube, airway obstruction occurs more frequently than you might guess, especially if the anesthetic requires a supplemental narcotic such as fentanyl in addition to propofol. In a busy day’s list of ten cases, perhaps four or five will require periodic jaw thrusts or chin lifts to keep the airway open.

An adage to remember:  “Anesthesiologists are experts in the management of Airway-Breathing-Circulation. You’re never so safe as when an anesthesiologist is watching every breath and heartbeat.”