Anesthesiology
An anesthesiologist is a physician specialist formally trained in the use of anesthetic drugs and techniques, pain management, and critical care medicine. Your anesthesiologist will formulate an anesthetic plan based on the type of surgery you are having and with consideration given to your concomitant medical problems. As always, our goal is to minimize the potential risks associated with anesthesia and surgery and to ensure that each patient has a positive experience. Whenever possible (i.e. safe), the wishes and desires of the patient and surgeon regarding the anesthetic plan will be respected.
Before surgery, your anesthesiologist will review your medical condition and explain your options for anesthesia. During surgery, the anesthesiologist will monitor you closely and make any necessary interventions to ensure your safety and comfort. Your surgeon and anesthesiologist will discuss any special needs you may have for postoperative care.
An anesthesiologist is a medical doctor who has completed a minimum of four years of residency training in anesthesiology (including internship) after graduation from medical school. A Certified Registered Nurse Anesthetist (CRNA) is a nurse who has earned a Bachelors degree in nursing (RN) and attended a two year nurse anesthesia training program. A CRNA must, by law, work under the supervision of a qualified licensed physician.
At GBMC all surgical patients are cared for by a board certified anesthesiologist and may also have a CRNA assisting in their care. An anesthesia team member will be present in the operating room at all times. The attending anesthesiologist does not leave the proximity of the OR suites when a patient is in his/her care.
You may be asked by your surgeon to be evaluated by your internist or family practitioner prior to surgery. This evaluation will determine if you are in optimal physical condition to undergo anesthesia and surgery. It will also provide important information which will help your anesthesiologist to determine the best type of anesthetic to offer you and to assess the need for any special monitoring techniques during surgery.
If you have heart disease, please ask your doctor to forward the results of any recent studies (stress test, cardiac catheterization, echocardiogram, etc.) in addition to their pre-op evaluation for review by the anesthesiologist. Occasionally, a visit to the cardiologist may be necessary. Other specialist consultations or tests may be requested to ensure that you are in the best possible condition for surgery.
Appropriate blood tests will be determined individually for each patient. Women of child bearing age will need a pregnancy test before elective surgery.
Try to reduce caffeine intake before surgery to avoid withdrawal headaches. Cutting down on cigarette use will help reduce your risk of pulmonary complications. Ideally, one should quit smoking 6 weeks before surgery but even 48 hours of smoking cessation has been shown to be beneficial.
Patients undergoing procedures with any type of anesthesia should arrive in the operating room with an empty stomach. Anesthetic medications may depress the cough reflex and allow any regurgitated material to enter the lungs where it may cause a severe reaction known as "aspiration pneumonia."
If you are scheduled for afternoon surgery it is still advisable to stop all food and drink after midnight since the operating room schedule is occasionally changed and your procedure may be moved to an earlier time.
Water is acceptable in small amounts up to 3 hours prior to surgery. No food or thick liquids (juice with pulp, milk, etc.) should be consumed for at least 8 hours prior to surgery. Any intake of non-clear liquid or food may cause your surgery to be delayed or rescheduled.
Please call your anesthesiologist for guidelines concerning infants and children.
Most medications can be taken the morning of surgery with a sip of water only. Non-clear liquids (such as orange juice, coffee with milk) take longer to pass out of the stomach and can cause greater damage if they should enter the lungs. Any intake of non-clear liquid may cause your surgery to be delayed or rescheduled.
The following are broad guidelines for some common medications. If you have specific questions, please call your doctor or call the hospital and ask for the Department of Anesthesia or the anesthesiologist on-call.
- Blood pressure medication- should be taken as usual the morning of surgery except for diuretics (fluid pills). Diuretic medications should be skipped the morning of surgery. These include Lasix (furosemide), Hydrochlorthiazide (HCTZ) and others.
- Insulin - consult your doctor.
- Oral diabetes medication - do NOT take on the morning of surgery.
- GLUCOPHAGE, a diabetes medicine, must be stopped 24 hours before surgery.
- Thyroid medication - can be taken
- Heartburn or ulcer medicine - acid blockers (Zantac, Prevacid, Pepcid, Axid, Prilosec, Propulsid, Reglan) should be taken on the morning of surgery to reduce the risk of aspiration pneumonia (see question #2). However, antacids like Maalox, Tums, or Carafate should NOT be taken because they contain particulate material that may damage the lungs if aspirated.
- Aspirin - consult your doctor
- Asthma inhalers- should be used the morning of surgery and bring them to the hospital with you.
General anesthesia means you will be completely unconscious during surgery. Since general anesthesia can impair normal breathing, some assistance with respiration is necessary. Most often a breathing tube is placed through the mouth into the windpipe (intubation) after the patient is asleep. This is removed as the patient is awakening and most patients will not remember having this tube in place. A mild sore throat lasting one to two days is, unfortunately, very common. In rare circumstances, tooth or airway damage may occur during airway management. Dentures should be removed before surgery. If you have loose teeth or a history of previously difficult intubation please tell your anesthesiologist. Special intubation techniques may be required for your specific situation.
Spinal or epidural anesthesia is most often used for procedures below the belly button. The nerves to the operative area are anesthetized with a combination of local anesthetic and narcotic.
Both procedures start with a sterile preparation of the back using iodine or alcohol solutions. A small area of skin, about the size of a quarter, is anesthetized with local anesthetic (numbing medicine). Then:
- a thin flexible plastic tube is inserted into the epidural space and taped along the back. Medications are continuously or intermittently injected to anesthetize the lower portion of the body. No metal or needles are left in the patient. This tube can remain in place as long as required and can be used to deliver pain medicine after surgery.
- a small hair-like needle is placed into the spinal fluid and medicine is injected. The needle is immediately removed and nothing remains in the patient. The anesthesia will last for a given amount of time (depending on the medication used) and then will wear off.
Most people report that spinal or epidural placement hurts less than starting an IV. In many cases sedation may be given before the spinal/epidural is placed and the patient will neither feel nor remember the placement.
- highly reliable, easier to place, very quick onset
- finite length of action, cannot be re-dosed if procedure takes longer then expected, not useful for post-operative pain management.
- can be re-dosed for long procedures and used for post-operative pain management
- harder to place and therefore less reliable, slower onset of numbness
Either technique may be combined with general anesthesia and in some cases combined spinal-epidural can be done for the quick onset of a spinal with the post-operative pain relief of an epidural.
Sedation is often used during regional anesthesia so that patients essentially sleep throughout most of the procedure. The level of sedation is determined by the procedure and the patient's medical condition and desires.
The hallmark of a spinal headache is a headache that becomes very intense when an upright posture is assumed and abates significantly when lying down. It may occur after a spinal or epidural anesthetic or after a diagnostic lumbar puncture (spinal tap).
A spinal headache is related to leakage of spinal fluid through a puncture site in the sac (known as the dura) surrounding the spinal cord and spinal nerves. The brain and spinal cord "float" in a fluid filled sac. When that fluid is lost, the brain will "sag" due to gravity when in an upright posture. The traction created on surrounding structures results in headache. Lying down provides symptomatic improvement but has not been shown effective in preventing the occurrence of a spinal headache.
During a spinal anesthetic, this sac is purposely punctured to inject medicine into the spinal fluid. Significant leakage leading to headache is rare because the spinal needle used is very small and the tiny puncture site heals quickly and doesn't allow much leakage.
During an epidural, this sac is usually not punctured, so a spinal headache is usually not possible. However, since the sac is essentially the "back wall" of the epidural space it can accidentally be punctured during epidural placement (~1%). Since the epidural needle is larger then the spinal needle (to accommodate placement of the epidural catheter), significant leakage leading to headache is more likely (~50% when accidental puncture occurs). The overall risk of a spinal headache after spinal or epidural anesthesia is about one in a hundred or less. Most are mild and short lived requiring no specific treatment. Conservative measures include bed rest, increased fluid intake, caffeine, and an abdominal binder.
For severe headaches, an autologous blood patch can be performed. An autologous blood patch is a highly effective treatment for a spinal headache. About 90% of spinal headaches will be relieved within 5 to 30 minutes and will require no further treatment. The remaining 10% will require a second patch.
The patient is usually given a dose of IV antibiotics prior to the procedure. The patient is placed in the sitting position and the back is sterilely prepared with iodine or alcohol solutions. A needle or catheter is placed in the epidural space exactly as it would be for an epidural anesthetic. Then a small amount of blood is sterilely withdrawn from the patient's arm and injected into the epidural space. This blood will clot and "patch" the hole in the dural sac, preventing any further leakage of spinal fluid. It also slightly compresses the sac, "buoying" up the brain, thereby quickly relieving the headache. The patient can then resume usual activities. There is no risk of introducing blood borne infections, such as AIDS and hepatitis, since the patients' own blood is used.
A blood patch is not without risk. There is a risk of infection occurring in the epidural space, a rare but serious complication. In some cases there may be transient back pain. This back pain may last minutes to hours. In rare instances it can last longer.
There are many factors that contribute to post-operative nausea and vomiting.
The type of surgery (abdominal and ear-nose-throat procedures), anesthetic medications (narcotics), changes in physiologic status (low blood pressure, irritation of internal structures, etc) and patient factors (more likely in patients prone to motion sickness) all interact and may contribute to nausea. In recent years, the armamentarium of anti-nausea drugs has improved significantly and has reduced the occurrence of post-op nausea. If this has been a problem for you in the past, please tell your anesthesiologist and prophylactic (preventive) medications can be given to reduce your risk.
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