General anesthesia is a type of anesthesia in which you are totally unconscious, having no awareness or any other sensations. General anesthesia is typically accomplished by using IV medications (sedative hypnotics, narcotics, muscle relaxants) in conjunction with inhaled gases. During your anesthesia you will be monitored at all times by a board-certified anesthesia provider using sophisticated equipment to constantly monitor all bodily functions. Once you are unconscious, a breathing tube may be placed through your mouth to maintain proper breathing and to deliver inhaled anesthetic drugs. The duration and level of anesthesia is continuously and precisely adjusted in response to numerous patient and surgical variables throughout your surgery. Upon conclusion of surgery your anesthesia provider reverses the process and you will regain consciousness while remaining comfortable, warm and safe in the recovery room.
Why can’t I eat before surgery?
While under anesthesia, you lose your protective reflexes such as coughing. However, it is possible to throw up and aspirate your gastric contents; in other words, whatever was in your stomach can end up in your lungs. If you have eaten or had fluids recently, there will be more acid and particles in your stomach. Aspiration of this could cause extensive damage to your lungs. This “aspiration pneumonia” was one reason many people died under anesthesia many years ago before fasting guidelines were instituted. During emergency surgery, many precautions are taken to limit the risk of aspiration pneumonia in patients with a full stomach. However, it is best to follow the fasting guidelines set by your anesthesiologist for elective surgery. You may be asked to take some or all of your usual medications with a few sips of water before surgery which typically dissolve and pass out of your stomach by the time anesthesia starts. Your anesthesiologist may also recommend that you take certain antacids prior to your anesthetic if you are at risk for aspiration.
How will I be evaluated prior to anesthesia?
The single most important thing we need to know is your medical history. At several points along the way you will be asked (sometimes redundant) questions. These are necessary to ensure your safety. In addition your anesthesia provider will usually do a brief physical exam focused primarily on your heart and lungs. In most cases, laboratory tests are unnecessary. We work actively with our referring surgeons and hospitals to eliminate unnecessary testing while retaining the blood tests, x-rays, cardiograms, etc., that are still likely to help us avoid complications.
Occasionally a referring surgeon will encounter an unusual set of circumstances that warrants a visit with an anesthesia provider well ahead of the planned surgery to create a comprehensive plan for the anesthetic. These pre-op consultations are arranged within the group practicing at the site involved.
Do I have to go to sleep for my surgery?
That depends on the operation you are having. Some operations are handled very well with either a major nerve block or a local anesthetic with sedation, rather than general anesthesia which induces a deep sleeplike state. These include procedures on the extremities, on the perineum, on the lower abdomen, superficial procedures like breast biopsies or long-term vascular catheter placements. Some operations that are typically done with a general anesthetic can be done with a regional or local anesthetic if the patient prefers to avoid a general anesthetic and will tolerate some minor discomfort to do so. You should discuss your options with your anesthesia provider before surgery.
Will I dream while I am asleep?
Anesthesia “sleep” is a drug-induced state of unconsciousness, and is very different from normal sleep. Under full general anesthesia patients do not dream. However, we don’t always give “full general anesthesia” –many operations are handled best with a nerve block, spinal, epidural or local anesthetic. It is common to give intravenous sedatives with these types of anesthesia. Occasionally patients will report having pleasant dream-like experiences with sedatives.
Will I recall anything during general anesthesia?
Every individual responds to anesthetic drugs differently. Infrequently some patients will remember parts of their experience when they were supposed to be asleep. In most instances it is just a fragment of a conversation they heard or sensations of touch or movement in the absence of any pain or anxiety. Most instances of recall occur in people with life-threatening injuries, massive hemorrhage, or medical emergencies requiring life-saving surgery. Such patients cannot tolerate normal amounts of anesthesia, which would depress their already stressed vital functions. These emergency patients get life saving measures and resuscitation first, and anesthesia second. Studies indicate that about 10%-15% of patients that survive these life threatening episodes will have some degree of recall of the events surrounding their life saving treatment.
Who will provide my anesthesia?
You will be cared for by a nationally board certified anesthesia provider. Anesthesiologists and CRNAs (Certified Registered Nurse Anesthetists) are the only clinicians licensed to provide anesthesia care in the U.S. Our practice is comprised of both CRNAs and anesthesiologists that work in a collaborative team environment to provide care to our patients.
Anesthesiologists are medical doctors that have completed a rigorous post-graduate training program including a clinical residency specific to anesthesia, and have passed a national board certification in anesthesia.
CRNAs are experienced intensive care or trauma nurses that have likewise completed a rigorous post-graduate training program including a clinical residency specific to anesthesia, and have passed a national board certification in anesthesia. CRNAs are board certified independent anesthesia professionals that have been providing safe, expert anesthesia care for over 150 years. CRNAs presently render over 32 million anesthetics in this country annually, and provide over 95% of all anesthesia care in rural hospitals in the US.
Will an anesthesia provider be with me the entire time I am asleep?
Yes, the standard of care in anesthesiology is that a competent anesthetist be in the patient’s presence continuously during the entire anesthetic.
How will I be monitored while I am asleep?
Every patient under our care has a continuous EKG, a blood pressure measurement every few minutes, a pulse oximeter, and a measure of body temperature. A pulse oximeter is a small electronic device that gives a continuous readout of the patient’s oxygen saturation/delivery. Since the biggest single source of untoward outcomes under anesthesia has been inadequate oxygen delivery, the ability to monitor the oxygenation status has seen a major improvement in patient safety. Patients receiving general anesthesia also have continuous monitoring of the percent of oxygen given in the breathing circuit along with measurements of carbon dioxide elimination.
There is a wide array of additional monitoring techniques, including indwelling lines (which measure blood pressures in the arterial tree, venous inflow to the heart, and the pulmonary artery), continuous EEG, nerve stimulators, Doppler blood flow monitors, trans-esophageal echocardiograms as well as many others that may be used in specific instances depending on the operation and the patient’s underlying health status.
How will my pain be treated after surgery?
There are great variations in the amount of pain a patient will experience based on the type of surgery and individual perception of pain. Some surgical procedures such as lung surgery and bone surgery can be very painful, while other procedures like cataract surgery are almost painless during surgery and the recovery period. Traditional post-operative pain management is usually addressed by moderate doses of intravenous or intramuscular narcotic medications and/or non-steroidal anti-inflammatory drugs.
Once you are eating and drinking adequately and your pain is well controlled intravenous or intramuscular medications can be switched to oral medication (pills) that have been ordered for you to take at home. Acetaminophen (e.g. Tylenol) with codeine, or similar analgesics are frequently used at this stage to provide pain relief. Occasionally, these medications are not adequate, so “breakthrough” pain medication (for example intramuscular morphine) may be given.
A popular method known as “patient-controlled analgesia” (PCA) works very well for most patients. With PCA, you are able to control the amount of pain medication by pushing a button which triggers a dose of narcotic analgesic. After each dose, you are “locked out” from getting any more medication for a prescribed period of time, after which you can initiate another dose. PCA is very safe and effective when administered as intended by the patient. Family members or others should never be permitted to press the button for you.
Continuous epidural analgesia is another method of pain relief that is very effective for more complex in-patient surgical procedures such as lung or abdominal surgery. Likewise, various types of nerve blocks are becoming more popular as a highly effective form of pain relief, particularly for orthopedic procedures. In some centers, a catheter (thin tube) is left in place to bathe the nerves continually with local anesthetic and provide round-the-clock comfort for surgical patients in the hospital or at home.
What are the common side effects of general anesthesia?
Anesthetics affect everyone differently. Below are some of the more common side effects noted by patients recovering from general anesthesia:
1. Drowsy and tired feelings for hours after surgery
Anesthetics wear off at different rates in different people. Most people are awake enough to answer simple questions within 5-10 minutes after surgery, although many have short term memory loss, so that hours after surgery you may feel as though it took a long time to wake up. Many people also feel tired enough to sleep for long periods of time after surgery even though they can easily be awakened. The pain medications you get after surgery may also prolong these feelings of sleepiness.
2. Post-operative nausea and vomiting
Historically, approximately 20% of people undergoing general anesthesia experience some degree of post-operative nausea and/or vomiting (PONV). If nausea has been a problem with past anesthetics, let your anesthesia provider know, as there are several interventions that can significantly reduce the incidence of PONV. Even though we can notably reduce the risk of this side effect, a minority of patients suffer from PONV. If you have a history of PONV which resists treatment, you may consider a regional or local anesthetic as an alternative to general anesthesia, depending on your surgical and anesthetic needs.
This occurs in approximately 10% of patients and is more common in patients prone to headaches and in patients who drink coffee (due to caffeine withdrawal).
4. Sore throat
While you are asleep you may have a soft plastic device in your throat to make sure your airway is open and air is moving in and out easily. Even when placed very carefully and delicately approximately 30% of patients experience some degree of a sore throat. This usually resolves in a day, but if there has been some difficulty in placing the plastic airway device, sore throat and hoarseness may persist for longer. Permanent damage to your throat or vocal cords is exceptionally rare.
5. Damage to teeth
This is also usually due to the plastic airway device. Damage to teeth can happen during placement (even if the anesthesia provider is very careful) or on awakening if you bite down very hard on the plastic. Be sure to let your anesthesiologist know if you have loose teeth or delicate dental work.
6. Awareness during surgery
Many people ask about the possibility of being awake and aware during surgery when they are supposed to be unconscious. This is exceedingly uncommon but may happen under unusual circumstances such as emergency surgery for a patient in shock. In such a scenario the patient’s vital signs may be so weak that they cannot tolerate much anesthesia. Remember that during a local or regional anesthetic you may be awake during all or part of the procedure depending on the amount of sedation given.
7. Serious complications
There are also a number of very rare but severe complications of general anesthesia such as injury to nerves, organs and possibly death. Some health problems may increase your risk of complications — please thoroughly discuss your health with your anesthesiologist.
Will I be nauseated or vomit after surgery?
Certain surgical procedures are more likely to induce nausea and vomiting than others. For example, operations on the eyes, ear, breasts, and bowel are more likely to cause nausea. Some individuals appear to be more susceptible to this problem, including those who experience motion sickness, and those who have previously had nausea or vomiting after anesthesia. When nausea and vomiting occurs, a variety of medications are available that can alleviate the symptoms.
Our nausea and vomiting rate is well below the national average as result of routine utilization of progressive anti-nausea therapy. If you have had major problems with nausea or vomiting after a previous surgery, please make a point of letting your anesthesia provider know, so that he or she can decide what anesthetic technique to use to minimize this potentiality.
Will I have a sore throat after surgery?
The insertion of the endotracheal tube or other type of “breathing tube” can result in a sore throat after the surgery. Sometimes a sore throat will occur even without intubation. This is usually not a major problem, but some people find it annoying. Throat lozenges can alleviate the symptoms. A persistent or severe sore throat should be reported to your anesthesiologist or your surgeon.
What is the risk of “not waking up” or dying during general anesthesia?
Exact data is difficult to come by for several reasons: 1) death from anesthesia is extremely rare, so gathering data for a denominator is a massive undertaking; 2) most deaths around the time of surgery occur from a combination of causes, of which the anesthetic may be only minor, 3) the nature of the American legal system encourages practitioners to be defensive and secretive. The best available data comes from a study of over 100,000 anesthetics in the early 70′s in Wales. Retrospective analysis there found that roughly one in 10,000 patients died from the anesthesia “alone” and that two in 10,000 died as a result, at least to some degree, of the anesthesia management.
Though it has not been well quantified, most informed sources put the risk today at well less than half of what it was in the 1970’s. Of note, 8.1% of the patients in the Welsh study received anesthetics that have not been used in the US in at least 15 years. Additionally, we get newer, better drugs all the time. Combined with the advent of pulse oximetry, carbon dioxide monitoring, and better training of personnel we believe the risk of dying today is closer to 1 in 50,000.
What if I have significant health problems like heart or lung disease?
Anesthesia providers frequently (on a daily basis) care for patients with heart disease, lung disease, kidneys problems, cancer, blood disorders, and many other pathologic conditions. They know how to deal with these problems from an anesthetic standpoint because they have had years of advanced training and experience caring for patients with complex medical problems. Your anesthesia provider will ask you a number of questions about your medical conditions to allow them to formulate a plan to minimize the risk associated with your specific medical history. He or she may even arrange for further tests or consultations with additional medical experts to learn more about your condition.
A relative of mine had a bad reaction to anesthesia, could it happen to me?
Most “bad reactions” to anesthesia are not life-threatening. There are two rare but preventable inherited conditions that we will mention here:
“Malignant Hyperthermia” (MH) is a very rare but serious hereditary (inherited) problem that is triggered by inhaled anesthetic agents such as Sevoflurane or the IV muscle relaxant Succinylcholine. MH causes severe metabolic disturbances and dangerously high temperatures during or after anesthesia. The exact incidence of MH is unknown. The rate of occurrence has been estimated to be as frequent as one in 5,000 or as rare as one in 65,000 administrations of general anesthesia with triggering agents. The incidence varies depending on the concentration of MH families in a given geographic area. High incidence areas in the United States include Wisconsin, Nebraska, West Virginia and Michigan. If you have a family history of relatives that might have experienced severe fever or other serious metabolic complications during surgery or during recovery from anesthesia you must inform your anesthesia provider.
“Pseudocholinesterase deficiency” is a condition in some individuals whereby they are unable to metabolize (break down) the drug Succinylcholine which is often used to relax the muscles during the surgery. As a result of their inability to metabolize this agent, the drug may last much longer than it would ordinarily. This is a rare problem occurring in approximately 1 in 3,000 people.
By providing your anesthesia provider with an accurate anesthesia history and details of what happened to you or your relatives they will be able to decide whether or not specific precautions in your case are necessary.
What if I have bad teeth?
Your anesthesia providers will want to know about any dental prostheses (false teeth, bridges, implants), tooth or gum disease, or cosmetic dentistry. This information is needed because of the risk of trauma or damage to teeth during the insertion of breathing tubes or other instruments. Obviously the danger is increased if a tooth is actually loose.
If you inform your anesthesia provider about dental prostheses, tooth or gum disease, or cosmetic dentistry, it will help avoid tooth damage. Special anesthesia techniques may be necessary. Sometimes, if a tooth is very loose or fragile, it is wise just to have it removed by a dentist before your surgery.
Does smoking have anesthetic implications?
If you are a smoker, our advice is to quit smoking as soon as you can! Smokers are more likely to experience breathing complications during and after anesthesia. Fortunately, these problems are usually managed without great difficulty. Smokers must also be especially careful to carry out deep breathing exercises after their surgery to prevent chest infection, pneumonia or other lung problems. The use of an incentive spirometer, a device which gauges your lung function, can be very helpful during recovery from surgery.
How long will I take to recover from my anesthetic?
The answer to this question depends on several factors, including the type of anesthesia you received, the length of your procedure, your underlying medical condition and your body’s reaction to the medications you have received. Most of the medications in use today are very short-acting and allow for rapid emergence, enabling many patients to go home on the same day of their surgery. Your anesthesia provider can give you a reasonable estimate for how long your recovery time will be, but each patient has a unique experience, and it is important to be flexible in your expectations. Also, patients often receive pain medication after their surgery and may experience side effects from the medication which are believed to be from the actual anesthetics.
When can I eat and/or drink after anesthesia?
Strictly from the viewpoint of the anesthetic effects, patients can drink fluids and rapidly progress to full meals as soon as they feel up to it. This may be within an hour after a minor procedure. After major internal alterations, however, especially those involving the brain, the mouth, or the GI tract, the patient may need to wait much longer. Your surgeon or doctor will give you more detailed instructions about what you may eat or drink after surgery.
Anesthetists have moved away from the old practice of requiring day-surgery patients to drink and retain (i.e., not vomit) fluids prior to discharge. Studies have shown that pushing early fluid intake only promotes post-operative nausea and vomiting. It is far better to wait until the patient feels thirsty, and this need not delay discharge home.
Will I become addicted to pain medicine if I receive it?
Many of the medicines used to control pain after surgery are in the family of opioids also known as narcotics. Some examples include Morphine, Hydromorphone (Dilaudid), Fentanyl, Vicodin, Percocet and Darvocet, among many others. While it is possible for patients to become addicted to narcotic pain medicines when used properly and as prescribed, the incidence of addiction is relatively low. Some of the predisposing factors to opioid addiction are certain psychiatric illnesses or having a history or a family history of substance abuse. Many patients withhold taking their pain medicine after surgery, for fear that they will develop an addiction, but when used for the purpose of treating surgical pain, narcotic pain medicine is very useful and effective. If a patient does feel that they are having a problem with addiction to pain medicine, they should seek help from a medical provider immediately.
Will I receive blood during my surgery?
You will be given a blood transfusion only if your anesthesia provider considers it absolutely necessary to protect your life and health. All blood given is tested for presence of the AIDS virus, Hepatitis B and C viruses and other infections, so the chances of getting these serious infections is extremely low. If your religion forbids receiving blood transfusions (Jehovah’s Witness and some others), please let us know so that the risks can be explained, the issues discussed in depth, and your wishes respected.
If I am awake afterwards may I drive myself home?
You may not drive a vehicle for 24 hours after receiving anesthesia. Whether you receive a general anesthetic or sedation for local anesthesia, you will be given medications to allow you to tolerate surgery or unpleasant procedures by relieving anxiety, discomfort, and pain. While current medications allow you to wake up quicker, the total elimination of these medications takes upwards of 24 hours. Thus, your ability to concentrate, make decisions, have normal reflexes, and safely drive will be hindered for up to 24 hours.
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