With any of the three
levels of sedation, you may receive an injection of local anesthetic to numb the
surgical site. You may or may not feel some discomfort as this medication is
injected, depending on how sedated you are.
(anxiolysis) is a drug-induced state during which
patients respond normally to verbal commands. The patient feels relaxed and will
sedation/analgesia (conscious sedation) is a
drug-induced depression of consciousness during which patients respond
purposefully to verbal commands, either alone or accompanied by light tactile
stimulation. Patients feel drowsy and may even sleep through much of
the procedure. Patients may or may not remember being in the procedure
sedation/analgesia is a drug-induced depression of
consciousness during which patients cannot be easily aroused but respond
purposefully following repeated or painful stimulation. Patients
sleep through the procedure with little or no memory of the procedure room.
Breathing is slow. With deep sedation, oxygen is normally given.
General Anesthesia is a
drug-induced loss of consciousness during which patients are not able to
respond and they are intubated with a breathing tube to help themselves
A topical cream is applied to the treatment site in advance or
an injection at the treatment site will numb only that area.
A topical local anesthetic is intended to be
applied directly to the area to be anesthetized, usually the mucous membranes of
When a local anesthetic is applied directly
to the mucous membranes or when it is injected around the nerve fibers, it
produces a loss of sensation by inhibiting the nerve excitation or conduction.
Drugs used in local anesthetic topical
Topical anesthetics relieve pain and itching
by deadening the nerve endings in the skin. They are ingredients in a
variety of nonprescription products that are applied to the skin to relieve the
discomfort of sunburn, insect bites, poison ivy, and minor cuts, scratches and
burns. These preparations are also used to help deaden an area first
before injections. Topical anesthetics come prepared as creams, ointments,
lotions and gels.
Topical anesthesia, in the form of lidocaine/prilocaine (EMLA Cream)is most
commonly used to enable relatively painless injections (such as BOTOX or Dermal
Drugs used in local anesthetic injections are usually:
Local anesthesia consists
of the area of the body to be operated on is anesthetized with a mixture of
Lidocaine (“Novocaine”) and epinephrine. Once everything is injected, the regions
are entirely numb and the procedure can be performed painlessly. The
epinephrine constricts blood vessels and therefore causes a lack of
vessel-dilating anesthesia medications.
Infiltration or injection
into the surgical area with a needle is the most frequently used local
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DRUGS USED FOR LOCAL ANESTHESIA BY INJECTION
used for injections on procedures lasting 30 to 60 minutes, is the most commonly
injected medicine. or longer procedures, longer-lasting medicines such as
Marcaine or Procaine:
is commonly added to the Lidocaine for longer procedures, as their duration is
much longer lasting than Lidocaine.
are often added to the local anesthetic solution to
constrict the blood vessels and delay absorption of the medicine. This can be
very beneficial for the patient by producing less bleeding and allowing for
longer anesthesia. Also helps with need for less medication. Epinephrine can
sometimes cause the heart to beat faster and stronger as it is absorbed into the
administration of drug
post-operative nausea and vomiting
recovery from anesthesia
Decrease in procedure
DISADVANTAGES OF LOCAL ANESTHESIA
Patients can feel the lidocaine needle sticks
Reserved for shorter procedures
Lidocaine toxicity is a
rare complication that can occur when anesthetic levels become too high.
Symptoms that can occur
from Lidocaine Toxicity:
Ringing in the Ears
Convulsions / Seizure
Very Low Blood Pressure
Irregular Heart Beat
severe forms of local anesthetic toxicity results in a very low blood pressure
in which the heart rate slows considerably and there could be an irregular heart
DRUG INTERACTIONS WITH LIDOCAINE (LOCAL
It is imperative that the
patient needs to tell their surgeon what drugs they might be taking on a regular
basis, as certain medication can interact with local anesthetics and increase
the risk of toxicity. The surgeon as well needs to be informed about all new
medications that the patient starts taking after the pre-op appointment and
What to expect from Local Anesthesia:
Topical cream might cause some skin irritation or dryness.
Injectable anesthetic agents might cause localized
swelling. Each local anesthetic will have a different
rate of toxicity, absorption and duration of action.
Tumescent anesthesia is a
common technique used for
liposuction. A solution of Epinephrine, Lidocaine,
and Saline is injected into the surgical area where the liposuction is going to
be performed. Tumescent anesthesia with highly diluted lidocaine and
epinephrine has transformed lipoplasty from a highly vascular surgery to a
painless and virtually bloodless office-based procedure.
The area after injection
becomes swollen immediately which comes from the surrounding tissue absorbing
How Tumescent Anesthesia
Saline helps separate
the tissues during the procedure – making the dissection much less traumatic
Epinephrine causes the
tiny blood vessels in the area to constrict, minimizing bleeding and
Lidocaine numbs the
area to provide pain control.
anesthesia, large volumes of anesthesia are used in much lower
The risk of Lidocaine
toxicity is greatly reduced.
ADVANTAGES OF TUMESCENT
advantages of the tumescent anesthesia include the following:
Significant less blood
is lost during the liposuction procedure.
Lidocaine is the
safest for tumescent liposuction of all the available local anesthetic
IV fluid replacement is not necessary.
lidocaine may decrease the risk of infections.
defects – hence making the likelihood of needing a secondary procedure less.
lidocaine sometimes is suctioned out with the aspirated fat.
The epinephrine may
increase the cardiac output, which increases the hepatic metabolism of the
The duration of
anesthetic effect may last as long as 24 hours.
The lidocaine may be
given safely up to 45 mg/kg and even higher in certain conditions.
DISADVANTAGES OF TUMESCENT
three risks of local anesthesia for tumescent liposuction are:
Toxicity from an
excessively high concentration of the drug in the blood
Injury from a needle
used to inject the local anesthetic drug
liposuction due to inadequate local anesthesia.
SIDE EFFECTS FROM TUMESCENT ANESTHESIA
Common side effects of tumescent lidocaine that are not
considered signs of toxicity include:
Mild sleepiness – some patients might experience some sleepiness during and
after tumescent liposuction, even if no sedatives are given.
Nausea and vomiting – nausea and vomiting associated with tumescent local
anesthesia is not common, but it can occur. Other drugs that are given
during the procedure such as antibiotics, sedatives related to Valium, and
all narcotics can increase nausea and vomiting.
TWILIGHT ANESTHESIA OR
CONSCIOUS SEDATION (IV AND ORAL)
Sedation” or complete sedation involves either a local anesthetic administered topically or by injection: A nerve block with
injection or sedation drugs (such as Valium, Ativan, etc.)
administered through an IV or orally.
If inserted by an IV –
this is usually placed in the inside of the elbow or on the back of
the hand. The needle goes in with an IV and once placed, it is
withdrawn with a little catheter left behind to deliver the meds and
saline solution to keep you hydrated during the procedure.
Twilight anesthesia is
also known as:
Intravenous Anesthesia (or TIVA) is intravenous sedation only.
Monitored Anesthesia Care (MAC)
Patients under twilight anesthesia are in a sedated state, but the patient may
not be entirely asleep. The anesthesia relieves the anxiety which the patient
might be exhibiting and also creates a state of amnesia so that the patient does
not remember the procedure later on. Many of the drugs used in twilight
anesthesia are the same drugs used for general; however the dosages are much
lower. IV sedation
is a good middle ground between local anesthesia (where the patient is awake)
and general anesthesia (where the patient is completely unconscious). It is
sometimes preferred to general anesthesia because patients recover more quickly
with less nausea and vomiting.
Twilight is different from
general anesthesia, as the patient is still breathing
spontaneously without a breathing tube inserted. Additional oxygen is delivered
to the patient through the nose with small plastic tubing. The anesthetist
follows the patient’s vital signs and delivers the medications through an IV.
The patient’s vital signs and other bodily reactions are monitored with a blood
pressure cuff, heart rate monitor, pulse oximeter (that measures the level of
oxygen in the blood), and an EKG machine. This type of sedation is normally
combined with injection of local anesthetic at the surgical site for additional
pain control and to minimize bleeding.
Most of these medications are very short-lived which requires a watchful and
experienced anesthetist to ensure enough but not too much relaxing and narcotic
medications. Once the medication drip is turned off, the patient regains full
consciousness within a couple of minutes ensuring a smooth awakening without
coughing and retching. Normally there is much less nausea with Conscious
Sedation than general anesthesia. Twilight anesthesia requires an
anesthesiologist experienced with conscious sedation, a skill usually mastered
by specialists working in day-surgery centers.
“Conscious Sedation” or Twilight can be given
The anesthesiologist will customize the cocktail specifically for the patient’s
Most of the time, an anti-anxiety agent such asValiumor
is given before the procedure to help with the patient’s anxiety.
As with any type of
anesthesia, the anesthesiologist will monitor you when receiving sedation
analgesia. These monitors are very important to ensure your safety. They are
used to monitor your heart rate and rhythm, blood pressure and the oxygen levels
of your blood. During moderate and deep sedation, someone will be solely
responsible for monitoring your vital signs and controlling your level of
IN IV SEDATION OR TWILIGHT
medication that is used with Twilight Anesthesia:
Versed is used often, as it tends to calm the
patient before entering the operating room. Versed relaxes the patient and
causes temporary amnesia, blocking memory of the first few minutes of the
strong narcotic pain medication in which it blocks pain receptor sites, lowers
blood pressure and heart rate, and can help with counteracting normal responses
to pain that occur during surgery.
Some of the newer narcotic drugs used are
along with the older drugs like Morphine and Demerol. All of these drugs off
long lasting narcotic pain relief that can be administered through the IV. Side
effect of all narcotic pain medication is nausea and vomiting.
Propofol which is also known as
Diprivan is a
popular medication that can induce moderate to heavy sedation without the
problems of disorientation afterwards. Once the drugs are stopped in the IV,
the patient will be awake within five minutes.
Ketamine can be given with the local anesthetic
is injected because it also makes the patient unaware of his surroundings. Side
effects with Ketamine include heart rate disturbances and hallucinations. Some
physicians are using a new anesthesia technique called PK – which is a
combination of Propofol with
ADVANTAGES OF TWILIGHT ANESTHESIA
Twilight anesthesia has
some distinct advantages over general anesthesia:
Allows the patient to
feel more comfortable and to minimize pain associated with procedure
Twilight carries fewer
risks than general anesthesia
allows the patient to be sedated yet not completely unconscious
Patients are able to
wake up easier from twilight
Usually less nausea is associated with
No airway intubation
thereby limiting potential lung complications
Local anesthetic is
used so the patient has less pain upon awakening
impediment of bleeding (which can also lead to bruising) intra-operatively
Twilight anesthesia should
always be performed by a
certified anesthesiologist, who will interview the
patient before the surgery and monitor the patient’s vital signs during the
actual procedure. A local or regional anesthetic is always applied to the
actual area having the procedure. This helps with the patient pain once they
are fully awake after the surgery. The drugs used in twilight anesthesia are
fast acting, and also quick to reverse, so the patient can be woken up in a
matter of minutes.
DISADVANTAGES OF TWILIGHT ANESTHESIA
any medical procedure, there are risks to twilight anesthesia.
Drugallergies or interactions are first and foremost.
Tell the anesthesiologist everything you take with
prescription and over the counter medication.
Having a complete blood count
done will also help the anesthesiologist with looking for any potential
who exhibit a great deal of anxiety should tell the
anesthesiologist so that they can use a deeper level of sedation.
experience with conscious sedation.
to expect from Twilight or Conscious Sedation:With some forums of sedation drugs you might feel nauseated and
sleepy. You should not drive for a minimum of 24 hours after
any form of sedation – nor should you be left without adult
This injection eliminates pain on a larger area
of the body. It blocks a group of nerves so that the pain
signal cannot reach the brain. An example of a regional anesthesia is an
“epidural” used during childbirth, or a spinal. This type of
anesthesia is used for many areas of cosmetic surgery; however
breast augmentation is not one of the usages.
nerve block or regional block involves injecting the anesthetic medicine at the
root of a particular nerve so that sensation is blocked along the branches of
that nerve. Regional Blocks require much less anesthetic medication which
lessens the possibility of toxicity occurring. There also tends to be a reduced
blood loss compared to general anesthesia since the medication used lowers the
blood pressure in the specific area that is being surgically worked on.
Regional blocks help with pain control by blocking it completely or greatly
reducing the episode. Regional anesthesia can block or reduce pain anywhere
from several hours to several days, depending on the medication and the
technique that is used. Some surgeons have been know to do a “nerve block” at
the end of surgery to reduce pain for the first few days during recovery.
Usually long or difficult
surgeries are not candidates for Regional Blocks. With regional anesthesia it
is injected around a large nerve or nerves. These nerves give sensation to the
site of the procedure. Regional blocks are normally used in addition to a local
anesthetic. Unlike local numbing, the medication is injected far away from the
procedure site. Although regional blocks cause a larger area of the body to be
numb than local anesthesia, the medication is the same. It takes a few minutes
for the medication to have its full effect, and the person should not be able to
feel pain in the area. Regional blocks also paralyze the muscles in the area. Sedative medications may be given before and during the procedure, usually
through an intravenous line, or IV.
COMPLICATIONS OF REGIONAL
BLOCK / EPIDURAL (SPINAL)
The most common complication of spinal anesthesia is a headache caused by
leaking of the cerebrospinal fluid.
Toxicity manifested by
light-headedness, tinnitus, numbness, feeling of anxiety, confusion, tremor,
convulsions, coma and cardio-respiratory arrest.
Nausea, sensory loss,
difficulty in breathing
to expect from Regional Anesthesia:A regional might cause the targeted area to be weakened, affecting
normal movement until the anesthesia wears off. You may
experience numbness, swelling and tingling in your extremities
depending on the area targeted.
anesthesia basically means that the surgical patient is completely asleep and
not aware of his or her surroundings. The patient
is given a drug that bring about a reversible state of consciousness so that one
is unable to experience any pain. The anesthesia is administered via inhalation
or by injection and can be used with or without controlled breathing through a
tube in the throat, known as intubation. When the
patient is intubated, a tube is placed in the windpipe (trachea) which is
connected to a respirator machine.
All control of breathing function is taken
over by the anesthesiologist who monitors the patient’s vital signs:
blood oxygen saturation
anesthesiologist uses all this data to decide which inhalation
gases and intravenous (IV) medications to administer to the patient. If the
surgery is going to be long in duration normally general anesthesia will be
used, to make it easier on the patient. Each surgeon will have their own
guidelines on what the protocol should be regarding patients and anesthesia.
General anesthesia should only be given in an
accredited or licensed facility in order to monitor the patient
closely and assure safety.
All licensed or accredited
facilities that allow general anesthesia should be equipped with a
CRASH CART in case of an emergency situation and only administered
by a licensed medical doctor whose specialty is an anesthesiologist
or nurse anesthetist.
uses sedating medications, usually Versed, to calm
and relax the patient before entering the operating room.
The Second Stage - "Going
or induction stage has strong drugs that are given through an intravenous (IV)
line to put the patient to sleep and control pain. Sometimes depending on the
patient and their needs a face mask is used as well. After going under, the
patient may be so sleepy that the tongue falls back in the mouth and blocks the
To prevent the tongue from
blocking the airway it must be protected and this can be accomplished in one of
- a plastic tube (endotracheal tube) is
inserted into the windpipe. This can sometimes cause hoarseness or a sore
throat for a few days after surgery.
– also know as “The LMA” This mask doesn't enter the windpipe, but forms a
seal around it to ensure that air is flowing into it, and minimizing the
risk of trauma to the throat.
Manually - lifting the chin and
moving the jaw forward with the patient. Since this requires someone to hold
the patient in that position, it is only used for brief amounts of time.
The Third Stage is known
as the "Maintenance Phase"
- in which the patient is kept comfortable and vital signs are monitored. In some
cases, the maintenance phase may last for several hours while the surgeon
performs the surgical procedure. During this time inhaled anesthetics
(medication in a gaseous form) can be administered with or without the help of a
ventilator (breathing machine)
The Fourth or “Coming Out” Stage
is near the end of the surgical procedure. The anesthetic vapors are turned
down and the patient slowly regains consciousness before being transferred to
the recovery room.
ADVANTAGES OF GENERAL
patient will have no memory of the surgery
anesthesiologist is in charge of monitoring all body systems while you are
under the anesthesia.
DISADVANTAGES OF GENERAL
procedure is considered the most invasive choice of anesthesia.
anesthesiologist or surgeons have no ability of communicating with the
Frequent post-operative nausea and vomiting can be side effects of general
Possible lung complications
Longer wake-up phase from anesthesia itself – sometimes long hang-over
Increase in procedure time.
to expect after receiving General Anesthesia:You
will awake like you have been in a deep sleep. Your throat might be a
little sore from the intubation of the tube down your throat. You might feel nauseated, but most
anesthesiologists take the necessary steps to prevent this from
happening by giving you a medication through the IV. Many
patients believe that anesthesia causes dryness of the skin and also
some hair loss. Staying well hydrated in the 48 hours
following general anesthesia is very important, regardless of how
Fortunately most "bad
reactions" to anesthesia are not life-threatening.
However, all forms of anesthesia including the different forms of local, can
carry a risk of an allergic reaction. Anesthesia exposes the body to
controlled levels of toxic chemicals in order to make sure there is no pain felt
during a surgical procedure. The main goal of anesthesia is to either stop
pain temporarily or to induce a semi-conscious or unconscious state. Even
though anesthesia carries a risk, the benefits outweigh any potential
The most important factor is making sure that
whoever administers the anesthesia are board certified in anesthesiology. By doing this, you reduce the risks of any complication that might arise during
surgery. All body functions and chemistry are monitored during your
surgery to ensure a safe procedure.
The most common reaction or danger of having
anesthesia is an allergic reaction to one of the medications used. This is
addressed immediately by the attending anesthesiologist by monitoring your vital
signs. If an allergic reaction occurs, your anesthesiologist is equipped to
handle this immediately. Severe allergic reactions during
anesthesia are fortunately rare.
It is very important to tell your
anesthesiologist every medication you take on a regular basis, so that he can
prevent any potential problem during surgery.
Malignant hyperthermia is a
very rare complication from
which can sometimes be
fatal. The inhaled
agents used in the
anesthesia can sometimes
cause a biochemical reaction
which is marked by intense
muscle contractions that
will eventually lead to
rigidity in muscle tissue.
Hyperthermia is another word
for an abnormal high fever
and muscle breakdown.
How Malignant Hyperthermia
This condition only
happens to patients who
susceptible to malignant
abnormal proteins inside
their muscle cells.
These proteins will
trigger the response or
release of excess
calcium when the person
inhales certain common
activates the sustained
muscle contractions -
which will increase the
amount of energy the
body will use
The end result is an
increase in heat
The overactive muscle
cells eventually run out
of energy and die off.
With the cells dying,
high levels of potassium
and a protein are
released into the
muscle damage, cardiac
arrest, brain damage,
failure, other organ
failure and death
These events can be
prevented if the
administers the proper
This complication is not
always fatal, in fact
death rates have been
Death rate during
1960-1970 was close to 80 percent -
Death rate today is
close to 10 percent.