The journal’s name may conjure up an image of a less-than-stellar publication. Research Notes of the American Astronomical Society may sound like a collection of off-the-cuff ideas or notations. Don’t let the title fool you; it is one of the top journals in astronomy and astrophysics. Published in that journal by Scott Sheppard et al. is a detailed account of his workhorse research effort that added 62 new moons to Saturn, bringing the total to 146, nearly double the number attributed to its larger brother, the gas giant Jupiter.
Sheppard had some tantalizing but shaky evidence that he’d collected from over twenty years ago, suggesting that there might be more moons orbiting Saturn. However, given limited telescope time—the competition for mountain-top telescopes is keen among astronomers—and the need to wait for technology to evolve, irrefutable proof finally emerged. The total moon count surprised him. An axiom likely familiar to you, the closer we look, the more we may see, seems particularly appropriate here.
This got us musing about our clinical practice, thinking about the many patients we care for who are taking drugs for their depression or other challenging mental conditions, almost all of which have considerable anesthetic care implications for our patients’ safety. We had just come across a new study in JAMA describing almost 300 new risk factors for depression. This work comes from a task force, part of the Psychiatric Genomics Consortium, that uses state-of-the-art tools to identify genetic links to depressive illnesses.
Mental illnesses are common domestically and around the world. It is estimated that more than one in five U.S. adults lives with a mental illness (some 60 million, representing 23.1% of the U.S. adult population). Mental illnesses include many different conditions that vary in degree of severity, ranging from mild to severe.
Examining genetic data (anonymized to protect identifiers) from over 5 million individuals—689,000 who had been diagnosed with major depression from an international sample—700 genetic links were identified. This identified 293 previously unknown risk factors. This new knowledge will likely help predict depression risk in a wide range of people and lead to novel or repurposed therapies. For example, pregabalin, used for chronic pain, and modafinil, used to treat narcolepsy, are believed to have great potential as repurposed agents for treating major depression. This intense effort is another example of the more one looks, the more one sees.
A not uncommon airway issue you need to look at very carefully to see
We recall from our training, experience, and the published literature that when caring for children and adults, even the most careful airway exam—challenging to do in a young child—may fail to identify lingual tonsil hypertrophy (LTH). There are over a dozen reports of previously unappreciated LTH, despite a green light after a clinically appropriate airway exam, that resulted in sudden and complete airway obstruction and the inability to mask-ventilate adults and children during anesthesia induction. LTH can also greatly impede laryngoscopy and intubation. Near-fatal and catastrophic outcomes have been reported. Beware, the mouth exam may not readily reveal its secrets!
Lingual tonsils are lymphoid tissue that usually resides on the posterior third of the tongue as part of a cluster of tonsilar tissues known as Waldeyer’s ring. All of us have four types of tonsils: palatine, lingual, pharyngeal, and tubal. It’s the palatine (also known as faucial) tonsils that are routinely surgically removed. Waldeyer’s ring acts as a kind of immunological sentry at the tenuous border of our respiratory and digestive tracts. Inflammation and swelling of the ring from infectious causes can completely obscure the supraglottic airway. Even without any inflammatory activity of Waldeyer’s ring, LTH alone can significantly impair ventilation, especially when assuming a supine position and the upper airway muscles are relaxed (e.g., sleep, ingesting alcohol, anesthesia)
CRNAs who have managed patients with previously unappreciated LTH will testify to the immediacy of airway loss and the difficulty of achieving a patent route to deliver oxygen. They may also feel a sense of confusion and dread after doing all the right things—a high-quality preanesthetic airway assessment—yet this anatomical surprise menacingly manifests.
Anesthesia is risky business, with the unexpected always possible
We might encounter many other “surprises” during otherwise routine care. For example, anaphylaxis to a drug we thought was safe to administer, or a child with undiagnosed cardiomyopathy who arrests during a virgin exposure to an inhalational sevoflurane induction. An otherwise asymptomatic patient experiences hyperkalemic arrest following succinylcholine administration, later found to have an undiagnosed myotonia syndrome, or a patient who emerges from general anesthesia with a motor deficit in a previously functioning arm despite appropriate attention to positioning. You rightfully fret for the patient and yourself, your mind racing, consumed by wondering if the doctrine of res ipsa loquitur will be applied against you.
Consider the risk of unremitting coma after shoulder surgery in the beach chair position. The latter condition is rare, but occurs frequently enough to have its own dedicated registry of reportable events. An exhaustive review of accumulated cases suggests that the etiology is a MAP falling below the lower limit of cerebral autoregulation—a metric subject to many influences and nearly impossible to determine in a patient during routine care. Then, among many other unexpected Beelzebubs, is the risk of methemoglobinemia from even a single mucosal spray of local anesthetic, which can impair the patient’s ability to oxygenate their tissues. A recent death during dental anesthesia in a child reminds us of this peril. Our specialty is not for the faint-hearted, that’s for sure. While things almost always go fine, a testament to our knowledge, skill set, and experience, we must not forget the “almost always” modifier in that testimonial.
Knowledge and technique are not finite but constantly evolving in the dynamic specialty you’ve chosen to work in. The closer we look, the more we may see, is an axiom we should hold dear. Whether gleaned from personal observations and reflections, professional communications, or listening to a colleague’s experience, we should never be complacent in seeking more information that will make us and our patients safer. Is it possible to see too much? We think not in our high-stakes specialty.
The recently detected moons of Saturn, obtained through a laborious analysis of telescopic data, offer new perspectives on how the solar system formed. Likewise, novel prediction models garnered from exhaustive analysis of major depressive illness databases are likely to lead to early lifestyle, behavioral, and drug intervention strategies.
It’s not always easy, and can be downright hard, to comprehend large things. Take the distance from the Earth to the Sun. On average, it’s about 93 million miles. Comprehending 93 million miles, or how far light—the fastest thing we know—can travel in a year, can befuddle us. We conveniently give the sun’s distance a moniker, an “astronomical unit,” and the light’s distance, as 1 “light year.” Think of M31, the Andromeda Galaxy, our closest galactic neighbor, which is 2.5 million light-years away from us. One light year is approximately 5.88 trillion miles, or 160 billion astronomical units. Using shorthand, such as astronomical units or light-years, allows us to conceptualize enormous phenomena into somewhat more manageable chunks that would otherwise risk overwhelming us.
Keeping it all manageable yet open to information upgrades
Patient safety while under anesthesia care requires distilling vast amounts of information into concise, actionable chunks to deliver point-of-care interventions. As with the big numbers associated with celestial musings, we compartmentalize what we need to know into digestible units. Everything we do derives from meticulous analysis of databases, prospective research, real-time patient events, and an ever-accumulating clinical experience. As evidence continues to accumulate, pathways are illuminated that lead to new approaches, new drugs, and new technologies, including artificial intelligence. The more one looks, the more one may see is indeed an axiom to embrace, as it reveals the importance of looking for things we’d not previously seen.
We understand the challenge of finding and earning CRNA CE credits while also maintaining a busy schedule. Whenever you’re ready, we have a course that fits what you need to meet the NBCRNA MAC program requirements.
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