The attending internist – anaesthetist drug expert for those needing anaesthetia/ analgesia, is a crucial lifeline for the patient who might otherwise see just the surgeon and GP.
And how many anaesthetists or surgeons first trained as specialist physicians in preventative medicine?
Apart from the primary role of the anaesthetist – safe life support, pain relief, and muscle relaxation through surgery- there are obviously at least seven other overlapping domains that the anaesthetist can improve if necessary, and bring to the attention of the patient & GP (as opposed to the surgeon & ICU specialist who would inevitably otherwise just focus on current problems):
1. Steroids- corticosteroids CS as the anaesthetist well knows, at the appropriate replacement (rather than rare pharmacological) dose, since relative CS deficiency or resistance is increasingly common in the older & sicker;
2. The Superhormones- Sex steroids & thyroid in replacement dose– deficient in at least half by midlife.
Various Swiss/German studies in ICU/ the ER have shown that men (and postmenopausal women) do worse than menstruating young women because the active well-housed gonads of the lattter are least perturbed by acute illness/acute injury. Thus men (who anyway clearly have androgen resistance compared to women – Bancroft’s hypothesis – involving apparent desensitization of the central nervous system to testosterone TT during early development in the male) suffer catastrophic fall in their main balancing anabolic immunomodulating hormone – testosterone – during major illness/injury. This cardinal hormone can easily be measured, and if suboptimal safely replaced if only temporarily with a single shot of Sustanon or Depotrone. The proportionate dose applies equally to the common androgen-deficient older woman. Similarly, thyroid deficiency can easily be measured immediately, and replaced with Diotroxin or even better Tertroxin initially.
The older patient needing major surgery may already as a consequence long have lost/ given up sex due to both illness and the causal or consequent fall in sex hormones – but sexual activity may well have become the only healthy exercise and antidepressant that many older people get if not need.
3. Secosteroid: relative vitamin D deficiency is increasingly recognized in all populations and agegroups, with the evidence suggesting that the optimal blood level is the upper quintile of the average adult ie around 100nmol/L to drastically reduce fractures, CVD, cancer, depression, autism and infections. Deficiency has probably increased as fish has become unobtainable, with rising dairy product intolerance, with increasing avoidance of sunburn, and with the forced hypocholesterolemia (from low cholesterol diet and statins) driven by the lunatic fringe who for profit insist that even normal levels of cholesterol are causal in vascular disease, not simply an effect of stress- and obesity-induced insulin resistance.
So, while vitamin D intoxication occurs only with intake in excess of 50 000 to 100 000iu daily, vitamin D is easily and cheaply boosted to near the optimal level with eg 50 000iu a week or about 6000 iu a day. Unfortunately it takes weeks to get a vitamin D level measurement back from up country (at a local cost of R660 ie US$66); but provided blood calcium , ALP & ESR etc do not suggest the very rare malignant hypercalcemia, it is harmless to give 50 000iu vit D pre-op, whether orally or sc..
4. the populist Synthetic designer but adverse drugs- Statins, sulphonylureas/ glitazones,oral HRT pills, bisphosphonates, antacids, NSAIDs non-steroidal anti-inflammatories, psychotropes, and most antihypertensives, – should be at least temporarily suspended preop and in ICU; since there is rarely justification for any of them, and they all cause significant morbidity.
statins are better replaced by fish oil, CoQ10 and other natural insulin-sensitizing antioxidants;
the fattening hypoglycemic- risky antidiabetic tabs by appropriate dose metformin +- insulin; only metformin halves mortality in diabetics, halves the incidence of new diabetics when used to promote weight loss & lower IGR in the overweight- and metformin plus androgen is antithrombotic, mildly thrombolytic and antilipidemic;
the gastrotoxic thrombogenic (and sudden-death eg Voltaren injection ) NSAIDs replaced by fish oil; paracetamol- opioid; and safe beneficial natural analgesic NSAIDs by a combo of curcumin-MSM -vit B5-cat’s claw-bromelain-boswelia, and for osteoarthritis and CVD protection, chondroglucosamine;
We have all had experience of anaesthesia, either as the patient, the relative or as one of the team. It may not always be good shortterm or longterm. Readers have been lucky- we were in good hands, and survived to be reading this.
so everyone can contribute some comment
with calmag-zinc, carnosine – glutamine-glycine-milk thistle to prevent gastric erosion/reflux and leaky gut, largely
replacing the H2 Antagonists and PPIs with their dizzifying effects.
HRT pills replaced eg natural physiological estradiol -progesterone- testosterone patch or cream;
no populist antihypertensives act for 24 hrs; the betablockers are now reserved only for ischaemic heart disease and arrhythmia because of increased risk; and the ACEI/ ARBs cause symptomatic let alone asymptomatic bronchial/angioedema risk in at least a quarter if not half of users;
whereas the best antihypertensive regime remains what has been proven in numerous trials for almost 50 years- lowdose reserpine 0.0625 (initially 0.125)mg/d plus lowdose coamilozide eg amiloretic 1/4 to 1/2 day. we seldom see patients who need amlodipine added as the best 4th drug choice for suboptimal control, provided they simply stop sugar, cooked fats and excess salt, and take routine fish oil, the other multisupplement discussed here, and appropriate metformin, and parenteral HRT (for men & women respectively);
prescription psychotropes: as substitutes, apart from the major benefits of natural parenteral HRT also as antidepressant and neuroprotection, there are the primary brain neurotransmitters melatonin and GABA gama-amino butyric acid let alone 5HTP 5hydroxytryptamine; all of these are usually appropriate, freely available, safe and relatively low cost;
and bisphosphonates replaced by all that is needed – appropriate combo of testo-estradiol; proline; the key minerals CalMagZincBoronMn;
and the key anabolic vits B6-B9-B12, C, D & K – especially to combat the rapid bone and muscle loss & delayed/ failed healing of major surgery, let alone prolonged immobility with complications.
5. safe oils – fish oil – should always be added pre-op, replacing (as capsules or liquid) both aspirin and the plant oil supplements (which are inflammatory) with the essential EPA + DHA at least a gram a day ie as 4 gm fish oil a day, which further help reduce constipation, thrombosis, inflammation- pain, depression, infection, memory loss and arrhythmia.
6. safe other supplements: added to the above in eg one drink twice a day: daily bcarotene 6000iu, the other vits B, E 400iu/d; and vit C to tolerance ie short of diarrhoea- eg 2-3 gm/d; orally / by n/g tube, but eg 1-5 gm in every vacolitre while on a drip;
the other minerals eg Cr, Mo, Se; and if appropriate iron.
N acetyl cysteine + guaifenesin as crucial lung protection;
and the magic quintet to reverse cardiovascular disease- CoQ10, arginine, carnitine, ribose and carnosine. (arginine is the key Nitric oxide substrate).
7. Screening: Fortunately very little needs to be added to what is already often routine before major surgery and in ICU: apart from baseline FBC creat elecs, LFT, calcium & redcell magnesium, there is appropriate testing for CK; iron; T4, TSH; glucose-insulin; and the steroid profile- cortisol; vit D, DHEA, testost, estradiol, progesterone & SHBG; and (rarely informative) FSH-LH.
8. Whose priorities and interests are served by perioperative / intensive care ICU prevention? Patients and acute response doctors, like gynes and other surgeons, traditionally focus only reactively on the acute presenting problem- not on long term prevention.
Obviously longterm prevention is against the shortterm interests of both patients (it takes too much discipline); and of private hospitals, the new drug industry, and private practice specialist internists & gynes- for whom only profitable disease pays; and against the interests of politicians- since the Disease Industry generate vast jobs and taxes (and opportunities for graft).
But the evidence from the literature and experience the past 50 years is that such prevention from admission can halve mortality, morbidity and complications including post-op confusion ie halve hospital stay and shortterm/ longterm incapacity.
Waiting for the major fracture before implementing lowcost safe effective preventatives may be worthwhile for the surgeon and hospital- but 20% die from the hip fracture, only 20% recover full health thereafter.
And only longterm androgen replacement may reverse the chief cause of osteoporotic fractures- frailty and falls. Nothing can reverse a fatal thrombosis, or chronic dementia, only early and permanent prevention can avoid these.