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Thursday, July 24, 2014
Awake or Asleep for Bard Chemo-Port implant
Recently, my wife had a Bard Chemo-port implanted at a Hospital in Delaware. She had been receiving cancer treatment with Bleomycin and requested to stay awake for the procedure. The surgeon agreed; however, the Anesthesiologist insisted that she be put to sleep and then administered 10 liters of oxygen per minute for 1 hour. We were concerned with the posibility of Bleomycin Pulmonary Toxicity and the increased risk associated with oxygen administration. Now the head of the department of Anesthesiology refuses to tell me what required her to be put to sleep for this procedure. Bard indicates that these units are usually implanted with the patient awake. Should we have had the final say in the decision to stay awake or go to sleep? Should the Department Head explain the decision to us? What can you tell us about Bleomycin and Oxygen aeministration? Please help me get some answers...
I am not familiar with the specific port you refer to. However procedures involving the insertion of ports for chemotherapy access are commonly done with mild to moderate sedation plus local anesthesia. There are ethical questions here, and medical ones. If you were in an American hospital it does seem surprising that your anesthesiologist did not or would not explain the choices that were made. But let us assume, for the sake of argument, that the anesthesiologist felt that this was the safest approach.
Anesthesia usually makes the procedure easier and quicker for the surgeon to accomplish, because less attention to the injection of local anesthetic is required. It may also be less stressful for the patient. Under these circumstances one would still normally expect the anesthesiologist to describe the risks and benefits of the different approaches available, and get your agreement to proceed in a particular fashion. Patients generally have the right to participate in decision-making and should ultimately assent to the treatment proposed. When patients make unsafe choices that is their right, however the practitioner is not under those circumstances obliged to go along with the patient's unsafe choice, unless that patient were deemed incompetent (in which case the physician might continue to do what is felt to be in the patient's best interests).
The issue of bleomycin and oxygen toxicity is an interesting one. An early study suggested that oxygen worsened the lung injury that can occur with bleomycin. Later studies disagreed with this finding. There seems to be a consensus now that the risk of lung damage from high oxygen concentrations is pretty low unless there is lung damage already or bleomycin has been given within the last 1-2 months. Because this is still an issue of some concern, it is likely that most anesthesiologists would try to keep the oxygen concentration to the minimum level needed to maintain good oxygen saturation levels in the blood.
Although oxygen toxicity might be a real issue, an anesthesiologist is likely to error on giving of extra oxygen to maintain adequate oxygen levels in the blood as needed. The risk of low oxygen is a real one, with very serious potential consequences, whereas for a relatively short procedure like port insertion the risk of oxygen toxicity may be more theoretical. I
t certainly sounds as though there has been a communication problem between you and the anesthesia team. If you are continuing to receive care at the same hospital it would seem like a good idea to try and arrange a meeting to voice your concerns, and smooth the way for future care. Your surgeon or another physician you trust might help arrange this. Alternatively many hospitals have a Patient Advocate whose job it is to sort out these kinds of problems.
Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University