Alfonso A. Tagliavia M.D.
Associate Attending in Anesthesia: Greenwich Hospital
Garland A. Cowan M.D.
Attending Anesthesiologist: Henderson, Nevada
Before your operation
During your operation
After your operation
Preface
Why are we writing this? Most people who have anesthesia for surgery have very little idea about what happens to the body during this period. Besides, anesthetic options available are not widely known. There is a lot of information available to us physicians, but very little, if any, is accessible to the lay public. With the information presented here, the fear of the unknown can be allayed, so that this most often stressful time can be made calmer.
The information contained in this book is a summary of some basic facts written in non-medical terminology. Unfortunately, in these changing times with the delivery of medical care so influenced by cost containment and rapid patient turn over, doctors are often unable to take the time to ensure that all of your questions are answered. Patients often have concerns but forget to ask them when they have the opportunity. Moreover, because the field of anesthesia is so specialized, information that you need may not be part of the knowledge base of a physician outside the specialty of anesthesia. It is our hope that patients can educate themselves with the aid of this book.
This is by no means a complete examination of the specialty of anesthesiology.
It is a short and simple guide to figuring out the big picture.
HISTORY
Before anesthesia, the best surgeons were the fastest. Four Herculean men would hold a patient on a gurney and surgery would proceed. Quick and simple procedures such as amputations were the majority of surgeries and most patients would just faint from the unbearable pain. With the advent of anesthesia, surgeons could proceed safely and carefully allowing delicate procedures to be performed without pain.
It has been over 150 years since the first anesthetic was performed, and even today, there are many questions that remain unanswered. It was William Thomas Morton who on October 16, 1846 performed the first public display of anesthesia in what is now called the Ether Dome at the Massachusetts General Hospital in Boston. A prominent surgeon at the time realized the implications and declared to his colleagues, "Gentlemen, this is no humbug!" A few months later in 1847, anesthesia was used to relieve labor pain and in 1853, Queen Victoria of England had anesthesia for the birth of her son Prince Leopold. Since that time the specialty of anesthesia has developed in many ways. Cocaine was first used to achieve topical anesthesia in 1884. Spinal and epidural anesthesia were discovered soon after and a combination of drugs was being used to allow optimal conditions for physicians to perform surgery.
The practice of anesthesia has developed into a specialty devoted to patient care before, during and after surgery. In 1935, the first anesthesia department was formed and today there are nearly 140 accredited training programs in the United States alone. Anesthesiologists complete four years of undergraduate training, four years of medical school followed by another four years of residency training in anesthesiology. Some go on even further to specialize within a field of anesthesia whether it be cardiac anesthesia, pediatric anesthesia, intensive care etc. During the residency, the physician completes several months of subspecialty training in all areas of anesthesia. Several months are also devoted to post-surgical intensive care units or ICUs. Many ICUs are run by surgical and medical departments but more and more are being run by anesthesiologists.
The anesthesiologist may be the person you know the least, but is the person who takes care of you during and after your surgery. There are generally two people whom you will encounter in the operating room (OR) performing your anesthetic. A CRNA or certified registered nurse anesthetist and an anesthesiologist. A CRNA is a registered nurse who has completed an additional two years in the practice of anesthesia. CRNAs are supervised by a physician who is usually an attending anesthesiologist.
The anesthesiologist you see may be an attending anesthesiologist, who has completed all the formal training in anesthesia, or a resident in training. Once the training period is complete, the physician has the opportunity to become board certified in anesthesiology. The American Board of Anesthesiology (ABA), which was founded in 1938, was formed to guarantee that an anesthesiologist meets a minimum requirement and has passed a standardized written examination as well as an oral exam before 4 representatives of the ABA. Once these exams are passed, the physician becomes a board-certified anesthesiologist and is free to practice and supervise residents and CRNAs. There are also several subspecialties within anesthesia such as pediatric, cardiac, neuroanesthesia, obstetric, critical care and pain management. The latter two subspecialties require an additional year of training and offer board certification as well.
Over the years there have been dramatic improvements in the medications we use for anesthesia. Ether is no longer used and drugs are shorter acting with fewer side effects. Patients awaken from anesthesia more rapidly, feeling less drowsy than in the past, allowing for earlier discharge from the recovery room.
There have also been tremendous advances in patient monitoring
including pulse oximetry and carbon dioxide detection. Pulse oximetry uses
infrared technology to measure the amount of oxygen in your blood by placing
a clip on your finger. As blood perfuses the finger, the infrared signal
'reads' the color of your blood and can estimate the percent of oxygen
in it. Carbon dioxide detection informs anesthesiologists that anesthetic
gases and oxygen are delivered to the lungs. Both of these advances and
others, have made the practice of anesthesia extremely safe. This monitoring
has allowed for better patient care and safety in the perioperative period.
Despite all these fancy and expensive monitors, the average anesthesia
bill amounts to only 5% of the total hospital cost. Efforts are always
being made to lessen the cost of anesthesia without compromising the quality
of patient care.
Safety
In the early days of anesthesia and surgery, dying "under the knife" was a real concern. Today, there are roughly 25,000,000 anesthetics performed each year in the United States, and death rates vary from about 30 to 960 per year. Although these numbers are small, they also include anesthetics performed for trauma and emergency surgery when the risk is higher. Elective surgery, therefore, carries a lower risk. This is an incredible improvement from the mid 1950s when the death rate was as high as 1/2000. Since it is such a rare event, it is very difficult to properly study bad outcomes solely related to anesthesia.
To place this into perspective, almost 6,000 pedestrians were killed
by cars in the United States each year between 1998 and 1999. There were
almost 45,000 traffic-related fatalities and 38,000 firearm related fatalities
in each of these years as well. Between 1990 and 1991 there were 73 fatalities
due to lightning, 46 fatalities to tornadoes and 102 people died in floods.
In 1992 almost 40 people died as a result of hurricane Andrew alone. In
Connecticut, there were 329 traffic crash deaths in 1998. But what
do all these numbers mean? Absolutely nothing. Your physical condition,
scheduled surgery, disease process and exercise capability, or lack of
it, contribute the most to the outcome. So basically, if you are young
and healthy, drove to the hospital and made it there in one piece, you've
likely passed the most dangerous obstacle. With improved monitoring, medication
and better understanding of diseases, anesthetic outcomes will only improve.
BEFORE YOUR OPERATION
(The Preoperative Period)
Preoperative Testing
Since over 50% of all operations are performed on an outpatient basis, many patients are seen at a preoperative evaluation clinic. Consent forms for surgery and anesthesia are signed at this time. Not everyone requires a preoperative evaluation and those patients can be seen on the day of surgery. If you are to have a preoperative visit, there are certain tests that you may need. The number of tests depends on your age, medical history, planned surgery and your surgery/anesthesiology team. Some of the more common tests include a chest x-ray, electrocardiogram (EKG) and some blood tests to check your blood count, blood type, clotting ability and kidney function. It may seem like a vampire is sucking all the blood out of you but the few tubes of blood taken for tests will not compromise your health. These tests are very helpful to the anesthesiologist who will need the information to take the best care of you. Most of these exams are precautionary, for instance blood type in case there is a need for a transfusion, but it is better to be cautious and have this information before it is too late.
Speaking of blood type, it may be possible for you to donate a couple
of units of your own, or autologous blood, in case you need it. This all
depends on the type of surgery you are having and any underlying illness,
e.g. cancer or blood disorders. There is a very small risk associated with
re-infusing blood and for this reason, not all physicians routinely re-infuse
donated or autologous blood. If there is no contraindication, then by all
means, donate blood. You may even have a family member donate for you if
you are the same type.
Preoperative Anesthesia Visit
This is the time to learn about your options for anesthesia and to ask questions. The interview can be done by telephone, but usually, you will meet with an anesthesiologist who focuses on your medical history, especially as it pertains to the surgical procedure you are to have. Other things we need to know about you are whether you, or other members of your family, have had anesthesia previously and if there were any adverse reactions. Your height, weight, medication you are taking and social habits are also noted. You should refrain from smoking before surgery and it is important to inform the anesthesiologist if there is a possibility that you are pregnant. A limited physical exam is also performed with special emphasis on your airway.
You should know that the anesthesiologist at the preoperative interview may not be the same person performing your anesthesia on the day of the surgery. A particular anesthesiologist can be requested for your case, but this should be done well in advance of the surgery to avoid scheduling conflicts.
There are three options with your anesthesia and most depend on the surgery at hand. The options are general anesthesia, regional anesthesia and monitored anesthesia care.
General anesthesia is usually required for major surgery. You will have an intravenous started and through it, you will receive medication that will make you unconscious. While you are asleep the anesthesiologist may help you breath or control your breathing with a ventilator. To do this, you will have a flexible breathing tube placed into your windpipe, or what we call intubation. Although infrequent, there is a possibility of teeth being damaged or dislodged during this procedure. This is why we ask you to open your mouth and about the condition of your teeth. It gives us an idea of how easy the intubation will be. You won't remember any of this because you will be asleep. After the breathing tube is secure, the surgery proceeds. Once the procedure is completed, the breathing tube is removed, usually before you wake up. The only time the breathing tube remains in place, is if you have had major heart or lung surgery or if you have really bad lung disease to begin with.
Regional anesthesia or a regional block, is a procedure done
to anesthetize a part or region of your body. This can be a finger, a hand,
an arm, a foot, a leg, an eye, a tooth etc. This is done by placing a small
needle or catheter near the appropriate nerves and numbing them with medications
known as local anesthetics e.g., Novocain. Spinals and epidurals can numb
you from the chest down and are also examples of regional anesthesia. All
the nerves in your body come from the brain and spinal cord and surrounding
these structures is a sac containing cerebral spinal fluid (CSF). CSF is
fluid the body produces which bathes the brain and the spinal cord. When
placing a spinal, a small needle is passed into this sac of fluid and local
anesthetic is deposited. This local anesthetic then bathes the nerves and
makes you numb in the areas they supply. The extent and duration of numbness
can last from one to several hours depending on what kind and how much
medication is used.
In contrast to a spinal, an epidural is a tiny catheter the size of
a guitar string ( 1-2 mm) which is placed near, but not into, the sac containing
CSF. Local anesthetic agents given through the catheter diffuse to the
nerves and have the same effect as local anesthetics given for a spinal.
The difference is that additional medication can be given through the catheter,
making the pain relief last as long as needed, even days after the procedure.
The risks with any regional technique are bleeding, infection and nerve injury. Bleeding is a complication seen especially in patients with clotting disorders and because of this, regional anesthesia may not be performed on such patients. The risk of infection is very small since all the procedures are done in a sterile manner. Nerve damage is also rare but because a needle is placed near a nerve, the risk must also be mentioned.
A common difficulty with regional anesthesia is failure of the block to work completely or quickly enough. We are placing a small needle or catheter near a nerve and sometimes do not get close enough. If this were to occur, it would be noticed preoperatively and the procedure redone to establish adequate anesthesia.
With a spinal, there is about a 1% chance of developing a headache. This is treated with bed rest, drinking a lot of fluids with caffeine, and pain relievers. The reason for the headache is that the tiny hole in the sac containing CSF does not close quickly enough causing a change in CSF pressure. Headaches occur most often with young females and the incidence decreases with age. Should the headache persist, other therapies are available e.g., a blood patch. A blood patch is exactly what it sounds like. Blood is drawn from your vein and placed in a sterile manner at the site where you had the spinal. This blood will then clot and form a patch over the tiny hole in the sac containing CSF. Headaches usually resolve within minutes after a blood patch but you should still stay in bed for a few hours to avoid any disruption of the clot.
Both
spinals and epidurals can be placed with you either in a sitting position
or lying on your side. You will be asked to curl your back like a shrimp
or the letter 'C' to better expose your spine to the anesthesiologist.
A soapy solution will then be used to sterilize your back and local anesthetic
agents, through a very small needle, will numb the area where the procedure
is to be performed. Anesthesiologists like to use a lot of numbing medicine
and feel there is no need for pain with any procedure. The numbing medicine
will feel warm as it goes in but should not be too painful.
Local anesthetics are used for all regional techniques. Dentists use local anesthesia all the time e.g. Novocain. There are two groups of local anesthetics and one group is broken down by the body into PABA, a chemical found in many sunscreens and makeup. If you are allergic or sensitive to PABA, it is important to let your anesthesiologist know so that he or she can use a local anesthetic from the other group. A true allergy to local anesthesia is rare. Most patients are allergic to the preservative in it or the PABA breakdown product, both of which can be easily tested for. Many patients are told that they are allergic to a local anesthetic but most reactions are the result of accidental injection into the bloodstream. If you were ever told you were allergic to local anesthetic agents, it is probably best to have skin testing done by an allergy doctor.
The last option for surgery is monitored anesthesia care (MAC) and it means exactly what it sounds like. Many procedures are accomplished with very little anesthesia or with local anesthesia given by the surgeon directly into the tissue to be operated on, for instance a breast biopsy. Under MAC, the anesthesiologist can provide some sedation while the procedure is performed. You may be awake the entire time and since most procedures are minor, they should be painless as well. If you do experience pain, the anesthesiologist can also give you some medication through your intravenous to make you comfortable.
For many procedures a flexible tube, or Foley catheter, is placed in the bladder to drain any urine made by the kidneys. The Foley catheter is usually placed after induction of anesthesia whether it be regional or general. Postoperatively, it is not uncommon for the catheter to give the sensation of having to void even if the bladder is empty.
If you have a regional anesthetic or MAC, don't be surprised if the
surgeon has some background music playing. This is a work environment like
any other and anything that makes someone more relaxed also improves performance.
You may even be allowed to choose the selection!
Food
The question always comes up about what to eat before surgery. Usually, patients are told to be "NPO" (nothing by mouth) after midnight. This means no food or drink after midnight. It is recommended that you fast at least 8 hours prior to surgery. NPO after midnight doesn't mean you should stuff yourself with cheesecake at 11:58 PM. Eat a normal meal in the evening and even a snack before you go to sleep- just as long as you go to sleep before midnight. Does this mean if your surgery is scheduled for 2 PM that you can eat breakfast at 6 AM? Not really. What happens frequently is that surgery begins sooner than scheduled and even if your surgery is at 2 PM, you should still fast after midnight. Your surgery may always be moved up !
The reasons for
these precautions are for your own safety and to help your anesthesiologist
protect your lungs. How does not eating protect your lungs? Well, anesthesiologists
try to do everything possible to prevent aspiration. Aspiration is not
something you "aspire" to but rather what happens when acid/food/liquid
etc. in your stomach, gets regurgitated into your lungs. This can have
a grave consequence, and the less food and acid in your stomach, the less
chance you will aspirate. Because of this, the recommendation is NPO after
midnight.
But why should someone aspirate you may ask? Well, general anesthesia for surgery causes you to lose all your reflexes including the cough and gag reflexes which protect your airway and lungs. While you are anesthetized or sedated, it is easier for anything in the stomach to be regurgitated into the lungs.
Some people are more likely to have food in their stomach despite being NPO for a long time. Patients with diabetes and reflux fall into this group and may be given an antacid or some IV medication to speed up the rate at which the stomach empties.
There are some exceptions to the NPO after midnight rule involving children
and babies. Newborns need to eat every 2-4 hours and therefore keeping
them NPO for 8 hours before surgery can really dehydrate them, not to mention
the screams the parents would hear if we suggested this. Newborns can have
formula up to 4 hours before surgery. They can even have clear liquids
e.g. water, apple juice or Pedialyte, up to 2 hours before surgery. Breast
milk is considered by some to be simialr to formula and mothers may nurse
their infants up to 4 hours before the surgery. For small children, the
clear liquid limit is 4 hours prior to the anesthesia. The longer they
can last however, the better. In any case, always check with the surgical
and anesthesia teams prior to any surgery.
What to expect
On the day of your surgery, you may be in for an early rising. Many insurance companies will not pay for a night in the hospital prior to surgery. So if your surgery is at 7:30 AM, you need to be in the hospital at 6:00 AM which means you may be getting up about 4:30 or 5 depending how far from the hospital you live. So try to get some rest the night before. Many people expect to rest while they're in the hospital. Big mistake! Often times a nurse may come into your room during your slumber and wake you to give you your scheduled medication, even a sleeping pill! Other times you will be awakened for blood pressure measurements or temperature checks. In any case, the recovery period can be exhausting and you should be well rested prior to admission. Remember, don't eat or drink anything you are not supposed to.
When you arrive at the hospital you will be asked to change from your
regular clothes into fashionable hospital wear. It may be drafty. Don't
bring a lot of belongings because the more stuff you have, the better the
chances of it being lost. Put your name on everything. You may even want
someone to come with you and take your belongings. If you are having outpatient
surgery, you will need an adult to take you home. A nurse will then check
your blood pressure, heart rate, temperature etc. and ask you a bunch of
questions. Be prepared to answer the same questions over and over again.
Any allergies? What kind of surgery? Where? When did you last eat? Don't
think that we don't trust each other by asking the same questions but this
is our way of minimizing mistakes. An intravenous will be placed, and this
may be the first time you meet your anesthesiologist. This is the time
for you to ask any questions that may have come up since your initial preoperative
visit.
Medication and Premedication
Once you arrive at the hospital you may be a nervous wreck. There are certain medications that can be given to get rid of the butterflies in your stomach. It is normal to be nervous prior to surgery and if you are not bothered by it and do not want any medicine, that's fine. Since it may be anywhere from 30 minutes to several hours before your surgery, sedation may be held until you get to a small preparation room we call a pre-induction area, where the anesthesiologist will give you something. The point is you should make your feelings known.
The other issue is with medication that you may be taking regularly. Medicine that affects your blood such as blood thinners (coumadin / warfarin) or aspirin, are usually held for several days before most surgery. Blood pressure medication, ulcer medication and sedatives are usually acceptable the morning of surgery. In fact, unless instructed otherwise by a physician, it is appropriate to continue with your regular medication. One very important medicine is that for diabetes. Pills or insulin injections may be held, or the dosage reduced on the morning of surgery. Diabetic patients are encouraged to keep a record of their blood sugar and the amount of medication taken. It is extremely important to check with your surgeon or speak with someone in the anesthesia department about this. Make certain to tell your doctors which medication you took the morning of the surgery. Be sure that you only drink a sip of water with your pills and not a quart of orange juice.
A common misconception by patients is not classifying supplements and herbal medications with prescription drugs. It is very important to mention every type of chemical you ingest. Diet pills, herbal medications and supplements are not regulated by the FDA, and many common over the counter remedies such as garlic, ginkgo and St. Johns Wart, may adversely affect the anesthetic management. Alterations in blood pressure, narcotic requirement, bleeding and clotting ability are just some of the potentially harmful side effects that can occur.
Once the intravenous is started and everything is set, you will be taken
to the operating room or a pre-induction area. At this point you will be
asked to switch from your stretcher to the OR table which tends to be cold
and narrow, so be careful. The electrocardiogram pads are next which are
also cool, even though they are not refrigerated. More monitors will be
placed according to the type of surgery and your overall medical condition.
Your anesthesiologist will explain what monitors you need beforehand. Once
all the monitors are on, pick out a good dream and before you know it,
you'll be back in the recovery room.
DURING THE OPERATION
(The Intraoperative Period)
What does the anesthesiologist do during the surgery? Anesthesiologists
are peri-operative specialists. This means that we are trained to make
informed judgments about your health before, during and after the operation.
As specialist physicians, our training spans the fields of internal medicine,
pharmacology, pain medicine and critical care. Together with anesthesia
applications, we attend to the vital functions of your heart, lungs and
other organs as they are affected by the surgery. We are prepared to respond
to routine and emergent situations as they arise.
Brain Surgery
Most patients have a general anesthetic for procedures on the brain. Some operations with the word "stereotactic" in the title may be done using MAC. Prepare to have your head shaved, if not completely then partially. Sometimes operations last a long time and because delicate areas are affected, postoperative ICU stays are not uncommon.
Upon awakening, you may have a headache. Physicians and nurses may be
asking you several questions to assess your mental function. Common questions
include: What is your name? When is your birthday? Who is the president
of the United States? Even if you do not like the answer, it is important
to try and respond to all the questions. Other neurological tests include
evaluating your reflexes, coordination and strength in all the major muscle
groups. During your recovery period, it is imperative to relay any new
symptoms of weakness or mental status changes to the medical personnel
taking care of you.
Face, head and neck surgery
A few additional points need to be made here about this type of surgery. More often than in other types of surgery, a breathing tube needs to be placed through the nose rather than the mouth. It sounds barbaric but it really isn't. You will be asleep when the breathing tube is placed. Rarely, because of the injury or disease process, the breathing tube is placed before you are deeply asleep. Sedation and medicines which numb the path taken by the tube are administered, so you'll be comfortable. Patients do not recall much if anything about what happened immediately before they fell asleep. On occasion, if the procedure lasts a long time or is extensive, the breathing tube may be left in until you are clearly awake and able to breathe without problems. You should be comfortable throughout.
Sometimes nasal or oral packings to minimize bleeding or rubber bands to improve dental occlusion, may be left in place after you wake up. This requires that you switch from nasal to oral breathing. The packings don't usually cause pain but can be uncomfortable.
Plastic surgery also falls into this category and many cosmetic procedures are done with local anesthesia or MAC. Because of this, you may be aware of what the surgeon is doing and feel pressure and vibration in the area being operated. You may awaken with bulky bandages which at times may cover your eyes. Pain is readily controlled and bruising and swelling should resolve gradually.
Another commonly performed operation is surgery for cataract removal.
It is usually an outpatient procedure done under regional block with either
the surgeon or anesthesiologist performing the block. This keeps the eye
numb and motionless. Not much else is needed and sedation can be given
if requested.
Heart and lung Surgery
Procedures in this category have come a long way since the old days and advances in anesthesia have allowed this evolution. For cardiac surgery, patients usually have an IV placed and adequate drugs given for sedation. Additional monitoring includes a catheter which is placed in an artery and functions to monitor blood pressure with each heart beat. At times a catheter is placed via a vein in the neck, into the heart, and gives information about how the heart is functioning and guides the anesthesiologist in using particular drugs and replacing fluids. During placement of this catheter, local anesthetic is given so that you should only feel pressure as it passes.
After you are asleep, an incision is made in the middle of the chest through the sternum and a heart and lung (or cardiopulmonary bypass) machine takes over the function of your heart and lungs. Many skilled physicians and technologists orchestrate the procedure to ensure that things go smoothly. At the end of the heart surgery, a temporary pacemaker is placed in case the heart beats irregularly afterwards. In most cases you will be taken, asleep, to an ICU which deals almost exclusively with heart patients. The breathing tube is then removed and invasive monitors are gradually discontinued. Surprisingly, pain is easily controlled with intravenous medication or injections. As you return to baseline you will be transferred to a regular floor to continue your recuperation.
For lung surgery, pretty much the same routine occurs, except going on bypass. An IV is started and depending on the extent and location of surgery, an epidural catheter may be placed. This is especially important for control of pain after the surgery because incisions across the chest are painful since the lungs and chest constantly move with breathing. Additionally at the end of the surgery, chest tubes may be placed by the surgeon to remove fluid build up and allow the lungs to fully expand.
An epidural catheter is frequently used on patients undergoing thoracic procedures. It is placed in the upper back because it is closer to the area of the incision. If you do not have an epidural, PCA (patient-controlled analgesia) is an option. The medication used in PCA can decrease your breathing and it is extremely important after thoracic surgery to fully expand the lungs to lessen the chances of developing pneumonia. So remember to take deep breaths!
Often, a special breathing tube is placed for thoracic surgery. This tube enables the anesthesiologist to control which lung expands and contracts when you are under anesthesia, allowing the surgeon to gain good exposure of the area to be operated on. All this is done while you are under general anesthesia so you are entirely unaware. Because you may require frequent monitoring, or if the breathing tube is left in place post-operatively, you will be taken to the ICU after surgery. If this is not required, an overnight stay or a regular stay in the recovery room is sufficient.
If there is a narrowing in your airway you may go to sleep by breathing
anesthetic gases. In days gone by, inhaling gases would cause you to cough
and gag but newer gases don't irritate the airway, so this too, goes smoothly.
For some procedures on the lungs e.g. bronchoscopy or lung biopsy, general
anesthesia is not required and patients do well with sedation and application
of local anesthetic to the throat and air passages. Frequently patients
are discharged home shortly after the procedure.
Abdominal and Pelvic surgery
Pelvic and abdominal surgery are commonly performed in the operating
room. You may be required to do a bowel preparation prior to coming to
the OR. Surgery on the lower abdominal and pelvic area can be done with
a spinal anesthetic and or an epidural. Of course, a general anesthetic
may be performed alone or in combination with these. Often, combining a
regional technique with general anesthesia decreases the amount of general
anesthesia needed. If an epidural is placed, it may be utilized during
and/or after the procedure to keep you comfortable. Remember that if you
choose a spinal or epidural anesthetic without general anesthesia, you
may have sedation through your IV to have a light sleep so that you are
unaware of the goings on in the OR.
Orthopedic Surgery
Orthopedic procedures are frequently performed on the upper and lower extremities. These procedures therefore are amenable to regional anesthesia. For the upper extremity nerves may be blocked to make the shoulder and any part of the arm numb for a period of time. In the case of the lower extremity, besides a spinal or an epidural, many nerves can be blocked to enable hip, knee and foot surgery to be performed without the sensation of pain. Remember, the operating room may sound a lot like a machine shop with drilling and hammering. Sedation is always available as you need it.
Spine surgery is performed under general anesthesia. Since this is a delicate area, additional monitors may be used to assess the function of the nerve pathways in the spinal cord, e.g., evoked potentials. Another way of assessing the function of the spinal cord is by a "wake up test". This means exactly what it says. After the main surgery has been completed, the patient is awakened from general anesthesia and asked to perform simple tasks such as moving the hands or feet. This is painless. Afterwards, deep anesthesia is once again achieved and the surgery completed. Most patients do not recall the "wake up test" but it is nice to know beforehand if one is to be performed.
Facial swelling is not uncommon after spine surgery since you will be
face down during the procedure. The swelling usually
resolves quickly and shouldn't interfere with vision. What may
affect visual acuity postoperatively is a history of diabetes and
high blood pressure. Make sure to discuss these conditions with
your surgical team.
Labor and Delivery
So you're having a baby and want to know what's going to happen and what options are available to keep you (and your partner) out of pain. Today, roughly one third of all women have an epidural for childbirth, but there seem to be two different attitudes about the whole process. Some women prefer to have no medication at all and want to feel everything. Other women would like to have the epidural placed three months before delivery and not feel a thing. The latter is very unlikely. However, there exist several choices including intravenous pain medication, spinal, epidural and regional anesthesia. General anesthesia in emergent and sometimes non-emergent situations, is always available. It is important that you make your wishes known to your obstetrician and to the nurse taking care of you during labor.
Childbirth can be vaginal or cesarean section (c-section). Women have c-sections for many reasons including a large baby, failure of the labor to progress or because the first child was delivered by a c-section. Having a previous c-section does not mean you will necessarily have another. VBACS, or vaginal birth after cesarean section, occur frequently. However, anesthesia is necessary for a c-section and for many 'natural' deliveries which may require an episiotomy or a small cut to facilitate delivery of the baby's head.
Does the anesthesia affect my baby? Well theoretically, anything in your bloodstream has the potential to cross into the baby's bloodstream. It has been proven that spinal and epidural anesthesia are safe for both the mother and baby. Since any anesthetic is administered by a qualified anesthesiologist, certain precautions are taken to ensure safety.
Will the spinal or epidural prolong my labor? Good question. The definitive answer is still being debated. Epidurals are usually placed during labor when the cervix is dilated to 3 or 4 centimeters. At this point, it does not seem to prolong labor. If it does, it is not for long and you should be comfortable the entire time. The relief of maternal pain by an epidural, may produce rapid cervical dilation and improved uterine contractions. This means that the epidural may even help labor progress! Ultimately, your obstetrician and anesthesiologist will decide when it is time to place the epidural. The medication used for pain control is very safe under monitored conditions and your heart rate, blood pressure and the amount of oxygen in your blood will be checked every few minutes initially and then per hospital protocol.
The duration and level of numbness can be adjusted by the anesthesiologist at all times. Since each labor is unique, you should make your wishes known as to how much you want to feel. Shivering is normal and can be annoying in labor, whether or not you receive anesthesia. You may not even feel cold! Remember that the NPO rules also apply during labor but ice chips may be acceptable. Check with the anesthesiologist at the hospital.
Most c-sections in the United States are done with an epidural if one is in place or with a spinal. Cesarean sections can take anywhere from 30 minutes to two hours or more depending on the obstetrician and the conditions encountered. If you have any questions regarding the c-section, your obstetrician should be able to answer them all. The more information you have, the better off you are at making decisions about your care.
If you do decide to have epidural anesthesia for your delivery, you
should be comfortable. Pressure from contractions may be felt but should
not be painful. This allows you to push when the time comes. After the
epidural goes in, the contractions will seem to get shorter in duration.
This is because you are not feeling the very beginning and end of the contraction.
Once you have delivered the baby and you are stable, the epidural catheter
is removed painlessly. As soon as you begin to eat, you can take pain medication
by mouth as needed. Ask your doctor what medications are OK especially
if you plan to breast feed.
Pediatric surgery
Children are not small adults and there is no such thing as a small anesthetic. They are a special category all unto themselves and this is why anesthesiologists who work with children usually have further training in this specialty. First off, before an infant or young child is anesthetized, the anesthesiologist will need to know about the early history. So, if there is anything remarkable about the pregnancy or the delivery do not hold back. Medical illnesses of your child will be extremely important because they sometimes impact the course of anesthesia severely. Be sure to mention recent colds, ear infections or exposure to chicken pox and other viral illnesses, so that adequate precautions may be taken.
As mentioned previously, because infants and children become dehydrated more easily than do adults, they have more lax NPO guidelines. If you have not adhered to these guidelines strictly, then tell the anesthesiologist. Usually something can be worked out, like changing the order of cases to delay your child's procedure.
Infants and some children do not react very much to being separated from their parents or guardians and so at the time of surgery, they may be taken by the anesthesiologist to the operating room. Some children will be O.K. with going there if their parent or guardian is with them. As a parent, your composure is essential for a smooth anesthetic. Other kids will require sedation in the form of oral or rectal medication. If pre-medication is given, the child may become 'floppy', so hold him or her securely to avoid injury. When the medication takes effect, it is important for the child to be taken as quickly as possible to the O.R. where he or she can be monitored.
The anesthesiologist will try to 'bond' with a child who is not pre-medicated and is not old enough to accept or understand what receiving anesthesia is all about. Your child may be given a mask whose function has been skillfully woven into the plot of a story, or one which is pleasantly scented to distract the child's thoughts from surgery. The most popular flavors appear to be strawberry and bubble gum. Again as a parent or guardian you may be able to accompany your child into the O.R., and as he or she becomes sleepy, you will be escorted away. It is very important to have children know that they are taking a special nap for surgery so that they will not associate sleep with being operated on. It is also important not to tell them that they will be 'put to sleep' because they may remember a pet that never returned.
At the end of the operation, children sometimes are fussy even if they
are not in pain. A strange environment, along with not being able to see
their parents when they wake up are usually the culprits. As usual, they
will be taken to the recovery room, monitored, then discharged home or
admitted. If your child goes home, it is very important to be vigilant,
attending to any new symptoms and irritability. At the same time, previous
symptoms like those occurring with recent immunizations or teething, should
not be confused as new. Your child may be more tired than normal, so allow
him or her to rest. If your child is admitted, you may be allowed to stay
much longer hours or even sleep over in the same room. If pain is an issue
then the appropriate specialist will be contacted.
After Your Operation
(The Postoperative Period)
The Recovery Room
Most patients go to the recovery room after surgery. If the operation did not require much in the way of anesthetic agents, then patients may be taken to the post recovery lounge from where they will be sent home. Sometimes if you will be admitted, you may go directly to your hospital room. If the operation was major, or if you need close observation, you will be taken directly to an ICU. The very vast majority of patients go to the recovery room after surgery. In the recovery room, monitors are placed, similar to the ones in the operating room. Pertinent information about your medical history and the anesthetic and surgical course are given to the nurse or other medical personnel who will take care of you. In the recovery room you will wake up more fully, and in fact, most patients think that they woke up after surgery in the PACU (Post Anesthesia Care Unit) rather than in the operating room.
Patients remain in the PACU until they are alert, vital signs are stable, and they are able to take care of themselves as expected depending on the kind of operation undergone. Pain, nausea and vomiting are issues in this setting, and the personnel in the PACU will administer appropriate care and medicines. You only have to let them know that you have a problem. A sore throat is not uncommon, especially if you were intubated for surgery. Patients usually feel thirsty in the PACU and ice chips, which will also soothe your throat, may be given. You should not, however, expect to have a meal here, as your gastrointestinal tract may not be back to its usual level of function.
A further word about pain. You should not have to bear very significant amounts of pain while in hospital. If an epidural catheter was placed previously, medication will be given through it. Most major institutions have a Pain Management service which can be called on by your surgeon if you have an epidural catheter in place or if your level of pain requires an expert in this field. The pain specialist may be an anesthesiologist or a neurologist who has a large armamentarium to control your discomfort. If you have chronic pain issues, you may want to ask for further information during your preoperative visit, or sometime before surgery.
Pain can often interfere with your recovery, especially if you have had a procedure in the upper abdomen or chest. If it hurts when you take a deep breath, you probably will not be taking many deep breaths, which is a big component of your recovery. Therefore, we need to keep you comfortable. A contraption we use to help you take deep breaths is called an incentive spirometer. It is designed to have you inhale and move a plastic ball which can be regulated to the amount of force you generate when inhaling. The purpose is to have you expand your lungs frequently and completely. This helps prevent your lungs from closing in certain areas and improves your ventilation. You can begin using the incentive spirometer in the PACU, on the floor or even at home after discharge.
When it has been determined that your postoperative course is stable and that you will only require routine nursing care, then you will be escorted to your room. Before you leave the recovery room, a physician, likely an anesthesiologist, reviews your course and then permits your discharge from the PACU.
Once on the floor, when your pain is controlled and you are utilizing the incentive spirometer, it is time to begin ambulating. Walking helps circulate the blood around your body, especially your legs. This minimizes formation of blood clots in your legs which can lead to phlebitis and even worse, a clot which goes from the legs to the lungs leading to respiratory problems.
Some people have difficulty walking even before surgery. For these people,
special 'air boots' are placed over the calves which inflate and deflate
to assist in circulating blood around your legs. Other patients may receive
heparin, a blood thinner, which is injected into the skin and also minimizes
clot formation. The goal is to prevent, as best as possible, the formation
of sludge and clot in the legs.
The Intensive Care Unit
Some patients are admitted to an ICU after their surgery. Patients who
had heart and lung procedures, those at risk for infection and those requiring
closer monitoring because of their disease process are some examples. In
the ICU, advanced monitoring is available and several physicians and nurses
are always ready to treat changes in a patient's condition immediately.
Again, when conditions are stable, you can expect to be discharged to the
regular patient floor in the hospital.
Discharge
As mentioned earlier, many patients are discharged home on the same
day as their surgery. It is extremely important to monitor yourself or
your child after a surgical procedure. Keep an eye on the bandages to see
if they are soaked with blood or fluid. Do you have a lot of pain or swelling?
Are you feeling nauseated, dizzy or lightheaded? If you had a regional
technique, is that part of your body still numb? Have a low threshold to
call your doctor or hospital and ask questions. It is advisable to refrain
from driving or making any important decisions for a day after your procedure.
There are anesthesiologists on call 24 hours a day who can be readily contacted.
If you are uncertain of how you should be feeling, just call and ask questions.
DEFINITIONS
Anesthesiologist - a physician who has completed four years of anesthesia training.
Aspiration -inhalation of stomach contents into the windpipe and lungs.
Attending -a physician who has completed the required training in a particular field.
Autologous Blood -blood that you donate for yourself prior to your surgery.
Board Certified -certification granted by an association stating that the recipient has fulfilled all the training requirements in addition to passing a written and an oral exam in that field.
Bowel Prep -enemas and other medications given to clean the bowel of any stool in preparation for surgery.
Capnograph -monitor used to detect exhaled carbon dioxide.
Carbon Dioxide -the gas that is exhaled every time one breathes.
Catheter -any flexible tube, e.g. IV, epidural, Foley.
Clear Liquids -water, apple juice, Pedialyte.
Coumadin -a blood thinner in pill form.
CRNA -certified registered nurse anesthetist. A registered nurse who has completed an additional two years of training in nurse anesthesia. Most CRNAs are supervised by an anesthesiology attending.
CSF -cerebrospinal fluid. Fluid that bathes the brain, spinal cord and nerves that come off the spinal cord.
Designated Donor -blood that is donated for you by someone you know with the same blood type.
Diabetes -a disorder of sugar control in the body.
Epidural Anesthesia -placement of a small catheter near the CSF so that an infusion of medication can be given continuously to achieve pain relief. Can be used during and after the operation.
Esophagus -the tube connecting the mouth to the stomach.
Ether -the first inhalation anesthetic used in 1846. No longer used in the operating room.
Foley Catheter -a plastic catheter placed into the bladder to drain urine.
Heparin -a blood thinner that is given as injection or IV.
ICU -intensive care unit. Can be cardiac, medical, neonatal, neurological, pediatric, respiratory or surgical.
Incentive Spirometer -a machine that is designed to expand your lungs after surgery.
Inhalation Anesthesia- General anesthesia achieved by the inhalation of anesthetic vapors.
Insulin -medication used to control the blood sugar.
Intubation -placing a flexible breathing tube into the windpipe to assist or control breathing.
IV -an intravenous. A plastic catheter placed in the vein to administer fluid or medication.
MAC -monitored anesthesia care- when a minor procedure is performed with the patient awake or mildly sedated by the anesthesiologist.
Malignant Hyperthermia- a severe inherited reaction to certain anesthetics.
NPO -nothing by mouth. Usually with a time limit: e.g., NPO after midnight.
OR operating room.
PABA -para-amino-benzoic-acid. A chemical found in many sunscreens and a breakdown product of certain local anesthetics.
PACU -post anesthesia care unit. Synonymous for the recovery room.
PCA -patient controlled analgesia. A device connected to the intravenous that delivers pain medication, which the patient controls.
Pre-induction area -an area immediately adjacent to the operating room where monitors are placed and IVs are started before the operation.
Pre-medication -medicine received before an operation: e.g., sedatives, pain medication, antacids.
Pulse Oximeter -a device used to estimate the amount of oxygen that is in your bloodstream.
Reflux - a condition that predisposes someone to heartburn.
Regional Anesthesia -when a part or "region" of your body is anesthetized for surgery.
Resident -a physician who is training in a particular field.
Sodium Pentothal -an intravenous medication that is used to make you fall asleep.
Spinal Anesthesia -placement of medication into the CSF to create a region of anesthesia, usually the lower body.
Trachea -the windpipe that connects the nose and mouth to the lungs.
URI -upper respiratory tract
infection.
Synonymous for a cold.
COMMON TESTS INFORMATION OBTAINED
CBC - Complete Blood Count - The number of white blood cells,blood count and platelets present.
Chemistry - The level of important minerals and electrolytes in your blood as well as kidney function.
Coagulation Profile - Whether or not blood is likely toclot sufficiently.
Urinalysis or UA - Presence of urinary tract infectionand kidney structure and function.
Chest X-ray - Anatomy of heart, lungs and other thoracic structures.
Electrocardiogram or EKG - Electrical activity of the heart.
Liver enzymes - Liver abnormalities.
Thyroid function - Activity level of the thyroid.
Stress Test / Echocardiogram - Assess heart function.
Angiogram - Anatomy of blood vessels. e.g., coronary angiogram blood vessels of the heart
Cat Scan or CT scan - High resolution x-rays.
MRI - Like a CT scan but without radiation.
Pulmonary function test - Lung function.
The Patient's Handbook of Anesthesia
MONITORS USED INFORMATION GIVEN
Blood Pressure Cuff - Blood pressure
EKG - Electrical activity of heart.
Pulse Oximeter - Amount of oxygen in your blood.
Capnography - Detects carbon dioxide.
Temperature Probe - Body temperature.
EEG - Brain activity.
Evoked Potentials - Spinal cord function.
Nerve Stimulator - Helps assess level of muscle relaxation.
The Patient's Handbook of Anesthesia
MEDICATION SHEET PATIENTS CAN TEAR OUT AND TAKE ALONG
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MEDICATION DOSAGE HOW OFTEN
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