Local Anesthesia for Minimally Invasive Spine Surgery: 4 Points on Propofol Use

Written by Laura Dyrda | November 17, 2011 | Print  |
Many healthcare providers in hospitals and ambulatory surgery centers are now choosing to use propofol in combination with other pain medications and anesthetics as an alternative to general anesthesia in the appropriate cases. Some patients may be weary of its use because it has been associated with patient death, most notably the death of pop star Michael Jackson.

"This is a drug that, under the correct circumstances, is ideal as an anesthetic because of its many properties," says Tonina Campoli, MD, anesthesiologist and medical director at The Bonati Spine Institute in Hudson, Fla. "It's a wonderful drug that has revolutionized anesthesia when it is used by a trained professional in a healthcare setting."

Dr. Campoli discusses how propofol has evolved into the ideal anesthetic and can be beneficial for patients undergoing minimally invasive spine surgery.

How we got here

Early anesthetic agents developed in the 19th century were inhaled anesthetics, which were difficult to administer and often fatal if not controlled properly. It was a major breakthrough in medical care when intravenous administration of anesthetic was developed for rapid drug administration straight to the bloodstream. Initially, the barbiturates administered would cause side effects, such as nausea, cardiac depression or excitatory myoclonic movements, but now anesthesiologists stray from these types of drugs.

"In a good agent, we want something that will rapidly metabolize without having active byproducts in the blood stream," says Dr. Campoli. "We want a minimal hypertensive reaction and heart decompression, and we don't want anything that will make you nauseous or vomit. We haven't found anything that does all of these things yet, but we have a few drugs that do these things in combination."

What a good anesthetic should accomplish

The primary targets of intravenous anesthetic agents are the ion channel link receptors for the neurotransmitters glutamate (principle excitatory transmitter) and GABA (principle inhibitory transmitter). The GABA receptor is in the family that includes the serotonin receptors, which are important to reach as well. "All intravenous anesthetic agents are trying to change these receptors," says Dr. Campoli. "You use these intravenous agents to target the receptors in the brain."

Propofol acts on the receptors to induce what is known as "anesthesia" — a hypnotic state where the patient loses consciousness, depending on their dosing schedule. In some cases, such as for minimally invasive endoscopic spine procedures, patients will still be responsive, but comfortable. This makes propofol ideal for the ASC because patients need to have the ability to wake up quickly and leave the ASC soon after surgery without feeling the symptoms that are associated with general anesthesia.

Appropriate propofol use in the ASC

Propofol is an intravenous anesthetic that has rapid redistribution and hepatic elimination, which means it rapidly returns the patient to consciousness with minimal residual effects. In many places, propofol has nearly replaced the old standard thiopental, which can cause more nausea and vomiting. Another advantage of propofol is that the plasma concentrations decrease rapidly when an infusion is terminated, so it doesn't linger in the blood stream for too long.

Dr. Campoli and the other anesthesiologists at The Bonati Spine Institute use propofol in combination with other drugs that locate the GABA receptor to induce amnesia such as midazolam, commonly known as Versed. "You can also pair propofol with Sufentanil, which is in the morphine family, and acts on pain receptors to ensure patients are feeling minimal discomfort during the procedure.”

When propofol can be dangerous

Professionally trained anesthesiologists understand the correct dosage of propofol for patients and have been educated on how to monitor their patients to ensure no negative side effects occur. However, if an unqualified anesthesiologist or medical professional administers propofol incorrectly, the ramifications could be lethal. "If the propofol is not monitored and is administered in an unregulated dosing regimen, it can cause tremendous respiratory depression, and you could stop breathing," says Dr. Campoli.

Adults and children require different dosing regimens, and various patient populations may need adjustments to the standard administration. If patients are already taking synthetic pain medication, and patients with chronic back pain often are, they may typically require higher than normal doses because they are already on such high doses of pain medication for daily maintenance.

Anesthesiologists constantly monitor the patient's heart rate and blood pressure throughout the procedure, and patients are given supplemental oxygen to ensure optimal safety. "With the appropriate monitoring of oxygenation levels and breathing patterns, anesthesia has never been safer."

As Dr. Michael Roizin, chairman of Cleveland Clinic Anesthesiology Division, has stated recently on the Dr. Oz show, "Propofol is an anesthetic, not a sleep aid! It is one of the best agents we have.”

There has been a shortage of different medications on the market due to several manufacturing problems. Fewer companies have to maintain and supply hospitals and ASC and it is difficult to handle the demand. There was a propofol shortage which has now been rectified. The medical community will encounter similar scenarios with regard to other drugs and further adjustments will have to be made in the future as we all navigate through these difficult times.

Related Articles on Spine Surgery:

Secret to Spine Surgery Center Success: The "5+3 C's"

Spine Center Network Creates Report Cards for Regional Spine Centers

Dr. Ken Pettine: Everything You Need to Know to Successfully Perform Spine Surgery in an ASC

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