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Your Anesthesia Options

 

 

                                 Anesthesiologist

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Although the effects of sedation are better described in terms of “stages” or being part of a “continuum,” sedation is usually divided into three categories.

The three levels of sedation are:

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.

 

1. Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. The patient feels relaxed and will be awake.

2. Moderate 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 room.

3. Deep 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 breathe.

 

 

                                                    Anesthesiologist

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Different Anesthesia Options Available

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 the skin.

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 preparations:

 

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 Fillers)

 

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 anesthesia technique.

 

                                          Local Anesthesia

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DRUGS USED FOR LOCAL ANESTHESIA BY INJECTION

  • Lidocaine: 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.

  • Epinephrine (adrenaline):  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 bloodstream.

 

 

ADVANTAGES OF LOCAL ANESTHESIA

  • Minimal administration of drug

  • No post-operative nausea and vomiting

  • No recovery from anesthesia

  • Decreased blood loss

  • Faster recovery

  • Decrease in procedure time

 

DISADVANTAGES OF LOCAL ANESTHESIA

  • Patients can feel the lidocaine needle sticks

  • Reserved for shorter procedures

 

 

LIDOCAINE TOXICITY

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

  • Dizziness

  • Convulsions / Seizure

  • Muscle Twitching

  • Unconsciousness

  • Cardiac Arrest

  • Very Low Blood Pressure

  • Irregular Heart Beat

The most 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 rhythm.

 

 

DRUG INTERACTIONS WITH LIDOCAINE (LOCAL ANESTHESTIC)

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 before surgery.

 

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 the medication.

How Tumescent Anesthesia Works:

  • 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 bruising.

  • Lidocaine numbs the area to provide pain control.

  • With tumescent anesthesia, large volumes of anesthesia are used in much lower concentrations.

  • The risk of Lidocaine toxicity is greatly reduced.

     

 

 

ADVANTAGES OF TUMESCENT ANESTHESIA

Several 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 drugs.
    IV fluid replacement is not necessary.

  • Bacteriostatic lidocaine may decrease the risk of infections.

  • Tumescence magnifies defects – hence making the likelihood of needing a secondary procedure less.

  • Lipid-soluble lidocaine sometimes is suctioned out with the aspirated fat.

  • Vasoconstriction minimizes absorption.

  • The epinephrine may increase the cardiac output, which increases the hepatic metabolism of the lidocaine.

  • 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 ANESTHESIA

The 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

  • Discomfort during liposuction due to inadequate local anesthesia.
     

 

 

COMMON 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)

“Conscious 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:

  • “IV Sedation”

  • “Conscious Sedation”

  • Total 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 by:

  •  Intra-venous (IV)

  • Oral

  • Gas

 

The anesthesiologist will customize the cocktail specifically for the patient’s needs. 

Most of the time, an anti-anxiety agent such as Valium or Ativan 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 consciousness.

 

 

DRUGS USED IN IV SEDATION OR TWILIGHT

The 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 injection. 

Fentanyl is a 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 Sufentanil, Remifentanil and Alfentanil, 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 Ketamine.

 

 

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

  • Twilight 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 twilight/sedation anesthesia

  • No airway intubation thereby limiting potential lung complications

  • Local anesthetic is used so the patient has less pain upon awakening

  • Epinephrine for 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

As with any medical procedure, there are risks to twilight anesthesia. 

  • Drug allergies 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 problems.

  • Patients who exhibit a great deal of anxiety should tell the anesthesiologist so that they can use a deeper level of sedation.

  • Requires anesthetist experience with conscious sedation.

 

What 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 supervision. 

 

 

 

 

 

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.

A 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.

 

 

                                  Regional anesthesia - Spinal or Epidural

                                              Copyright 2010 ADAM, Inc. - Used with permission

                                                   Location of the Spinal / Epidural

 

 

ADVANTAGES OF REGIONAL BLOCK ANESTHESIA

  • Many anesthesiologists believe that regional anesthesia is a safer alternative to general anesthesia

  • Reduced post operative mortality caused by a blood clot or myocardial infarction (heart attack)

  • Improved post operative pain relief

  • Improved post operative responsiveness

  • Shorter recovery period compared to general anesthesia

 

DISADVANTAGES OF REGIONAL BLOCK ANESTHESIA

  • Permanent nerve injury

  • Symptoms and signs of epidural hematoma (including swelling and bruising)

  • Risk of systemic toxicity if the anesthetic is absorbed through the bloodstream into the body

  • Heart or lung problems

  • Infection at injection site

 

 

                                              anesthesiologist tools

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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.

  • Hypotension

  • Nausea, sensory loss, difficulty in breathing

 

What 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.

 

 

 

 

 

General 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:

  • heart rate

  • electrocardiogram (ECG)

  • blood oxygen saturation

  • blood pressure.

 

The experienced 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.

 

 

                                                crash cart

                                                    Photo image courtesy of Lifeline

                                                      Image of a Crash Cart

 

 

 

 

 

There are four stages of general anesthesia:

 

The "Pre-Medication" Stage uses sedating medications, usually Versed, to calm and relax the patient before entering the operating room.

The Second Stage - "Going Under" 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 airway.

 

To prevent the tongue from blocking the airway it must be protected and this can be accomplished in one of three ways:

  • Intubation - 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.

  • Laryngeal mask – 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 ANESTHESIA

  • Painless procedure

  • The patient will have no memory of the surgery

  • The anesthesiologist is in charge of monitoring all body systems while you are under the anesthesia.

 

 

DISADVANTAGES OF GENERAL ANESTHESIA

  • This procedure is considered the most invasive choice of anesthesia. 

  • The anesthesiologist or surgeons have no ability of communicating with the patient.

  • Frequent post-operative nausea and vomiting can be side effects of general anesthesia. 

  • Possible lung complications

  • Longer wake-up phase from anesthesia itself – sometimes long hang-over effect

  • Increase in procedure time.

 

What 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 you feel. 

 

 

 

 

 

                                 anesthesiologist

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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 disadvantage.

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 general anesthesia, 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 Happens:

  • This condition only happens to patients who are genetically susceptible to malignant hyperthermia

  • Patients produce abnormal proteins inside their muscle cells.

  • These proteins will trigger the response or release of excess calcium when the person inhales certain common anesthetics

  • Increased calcium activates the sustained muscle contractions - which will increase the amount of energy the body will use

  • The end result is an increase in heat production (hyperthermia)

  • 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 bloodstream causing muscle damage, cardiac arrest, brain damage, massive internal bleeding, kidney failure, other organ failure and death

  • These events can be prevented if the anesthesiologist administers the proper treatment immediately 

  • This complication is not always fatal, in fact death rates have been dropping significantly.

  • Death rate during 1960-1970 was close to 80 percent - Death rate today is close to 10 percent.

  • Very rare complication

 

 

 

 

 

 

 

 

 

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