Drugs, Anesthesia & Risk

    NOTE: Material on this page does not constitute medical advice. Consult with your physician concerning specific medical conditions.

    What is the name of the drug given I.V. that makes you go to sleep before surgery?

    Intravenous drugs which produce "sleep" are called hypnotics. There are a variety of drugs that can be used. However, the two most commonly used drugs are sodium pentothal and propofol.

    My mother died from a "probable reaction" to anesthesia. I am going to have a D&C which will require anesthesia. I have a history of pvc's and negative reactions to most drugs including pain killers, antibiotics and antihistamines. What would be the safest type of anesthesia for someone with my history and needing a D&C?

    The fact that your mother may have had significant problems related to an anesthetic is important information which should be communicated to your anesthesiologist when you visit with him or her. As to your best choice of anesthesia, there are several ways to go. Spinal anesthesia would be a good option since it would involve one drug, a local anesthetic. However, if you would prefer a general anesthetic , TIVA, total intravenous anesthesia, would work well.Talk with your anesthesiologist and together work out a safe anesthetic plan for you.

    Is there another option for surgery besides general anesthsia? I am a diabetic. What about propofol?

    There are options to general anesthesia. However,these options vary with operative site, training of your anesthesia provider and needs of your surgeon. The options , other than general anesthesia, include spinal or epidural anesthesia. These are used mainly for surgeries on the lower extremities and lower abdomen.Peripheral nerve blocks with local anesthetics can be used for shoulder, arm and leg surgery. Local infiltration with local anesthetics can be used for superficial surgical procedures almost anywhere on the body.

    Diabetes does not preclude the use of general anesthetics. Diabetic patients undergo general anesthesia daily and the vast majority do extremely well.

    Propofol is an intravenous drug which produces "sleep". It is frequently used as an induction agent for general anesthesia. After the airway is secured an inhalation agent is administered to provide surgical anesthesia.

    Inhalation anesthetics are liquids which are converted to a gas so they can enter the body through the lungs. Propofol may also be used as a continuous infusion via the IV to keep the patient "asleep".

    As with any pending surgery, you should talk with your anesthesiologist as well as your surgeon and learn what options are available to you for your given procedures.

    I am exploring nerve block as well as local anesthesia for shoulder surgery. Please advise me of the advantages and/or negatives of this extra procedure.

    You have chosen a good path to explore the possibility of nerve block for your rotator cuff and tendon repair of your shoulder. The primary advantage of using a nerve block for shoulder surgery is reduced postoperative pain. Shoulder surgery can be associated with a fairly significant amount of discomfort. With a nerve block this discomfort can be eliminated or greatly reduced for anywhere from 15-30 hours. Of course, there are certain risks associated with nerve blocks (bleeding, infection, drug reaction, nerve damage). The likelihood of them occurring is small, but it exists.

    Usually, anesthesia for shoulder surgery of this type is one of the following:

    Nerve block- This often consists of an interscalene approach to the brachial plexus (the nerves which supply your shoulder and arm) and involves placement of local anesthesia above the collarbone to numb the area around the shoulder on that side.

    Nerve block plus general anesthesia- Often patients having the above nerve block require or request sedation or general anesthesia in addition to the block for the surgical procedure. The block can make the sedation or general anesthesia course smoother, fewer side effects from general anesthesia, such as nausea, and then after the operation, the block can provide several hours of post operative pain relief.

    General anesthesia only- Patients who are not good candidates for a block may best have general anesthesia only

    Local anesthesia alone placed at the surgical wound area is usually not sufficient to provide pain relief for the surgical procedure itself, but local anesthesia can be added at the end of the procedure to help provide pain relief in the post operative period.

    After receiving input from both your surgeon and anesthesiologist caring for you, a block or local anesthesia can sometimes be of very good benefit to patients having this type of surgery.

    Each patient and surgical procedure must be individualized and so one size does not fit all. Therefore, it is probably best to discuss these options with your anesthesiologist who can involve your wishes and specific health issues in helping choose the best course for you.

    I would like to know what are the risks for someone that is pregnant? Will the anesthesia hurt the baby? This person is only 7 weeks pregnant.

    When a woman is pregnant, the first 12 weeks are the most critical in the baby's development, as all organs and major structures are formed during this time. Therefore, most elective surgery is delayed until after the 12th week of pregnancy. If the surgery is not elective (ie, the mother’s health is at risk without the surgery), the procedure may need to be done urgently or emergently.

    There is very little data on the safety of most drugs used during pregnancy, including many of drugs which may be part of an anesthetic. Some medications have known risks to the fetus and are easily avoided. Other drugs have been used safely during pregnancy for many years and are the preferred anesthetic agents for early pregnancy. Of course the type of surgery is important as well, with a higher risk to the fetus with abdominal surgery versus repair of a broken wrist, for example.

    The most important point is for the woman having surgery to let both the surgeon and anesthesia team KNOW that she is pregnant, then discuss her options about timing of surgery and which anesthetic drugs will be used.

    When may regional anesthesia be used for laparoscopic lower abdominal surgery? I wish to avoid general anesthesia. My upcoming surgery would be performed with me in the Trendelenburg position and a CO2 pneumoperitoneum established. An anesthesiologist from a well known clinic has told me that such procedures are regularly performed this way. It can be a bit uncomfortable but most individuals tolerate it well. The hospital at which I am having the surgery has no experience at performing laparoscopic abdominal surgery without general anesthesia. I encountered a similar situation several years ago for a TEP hernia repair. I convinced the surgeon to allow me to have regional anesthesia and all went well. Can you help me sort this out?

    Laparoscopic procedures that are performed with an inflated abdomen are most commonly performed with general anesthesia. Performing such procedures using regional anesthesia requires that both the surgeon and the anesthesiologist be comfortable with performing the procedure in such a manner. If you wish to have the procedure done under regional anesthesia then it would probably be best to find a surgeon who normally does their laparoscopic procedures that way. That surgeon will also have anesthesiologists who are willing to perform regional anesthesia for your surgery. It is not in your best interest to try to make your surgeon and anesthesiologist use a technique that they are not comfortable using. Regional anesthesia may be useful for patients having laparoscopic procedures to localize pelvic pain, where an awake patient can help localize and characterize the pain. This technique is done with an intravenous anesthetic that allows the patient to be deeply sedated at times, then awake enough to respond to questions. Most patients can tolerate this quite well, although they are highly motivated and carefully selected, with no contraindications such as pulmonary disease, acid reflux or severe obesity.

    However, any significant pneumoperitoneum (or any inflation pressure greater than 15mmHg), coupled with the Trendelenberg position makes it almost impossible for a patient to maintain adequate air exchange. The elevation of the diaphragm and upward pressure from the abdominal contents will make the patient very uncomfortable to begin with, and overtime, as CO2 builds up from inadequate alveolar ventilation, a significant feeling of air hunger will ensue. If the procedure can be done without the pneumoperitoneum, the patient may be able to tolerate it comfortably under regional anesthesia.

    General anesthesia is considered very safe and in most healthy patients relatively free of side-effects.

    I am terrified to get my wisdom teeth removed. I have never "been under" and I am worried about the mortality rates of using anesthesia. Would you be able to give me some info on the seriousness of going under and the risks involved with my procedure? Thank you

    The amount of surgery performed in outpatient clinics for the past 26 years attests to the safety and effectiveness of this setting for medical operations. In general, the risk of a experiencing a major complication in an otherwise healthy patient is extremely low, but not impossible. For example, there is always the remote chance that a patient may have a reaction to a medicine that may not have been predicted. Sometimes this may be life-threatening, but this is the very reason that your physical status (vital signs) will be so closely monitored throughout the surgery and perioperative period. Concerning the risk of death, some figures may be illuminating. If you are healthy and undergoing minor surgery, your risk of dying from anesthesia is probably less than 1 in 200,000. By comparison your lifetime risk of ever being struck by lightning is 1 in 10,000 (20 times greater) and your risk of actually dying from a lightning strike is 1 in 30,00 (about 7 times greater). If you drive 1,000 miles, you have about 1 in 42,000 chance of dying or about 5 times greater risk than dying from anesthesia. Concerning the risk of death, in general, it's probably riskier to die crossing a street in a big city than it is to die during or after general anesthesia.

    Anxiety about surgery and anesthesia is normal, so please share your concerns with your anesthesia care team and ask any questions you have. We recommend that you contact your physician first to discuss your concerns

    What can I do or say to ensure I receive adequate anesthesia for op surgeries or procedures? It's a nightmare for me to wake up during a surgery, etc. when I've told them that I seem to need more anesthesia than the average patient. I've just had a breast biopsy and actually felt the dr cutting into the lump during the biopsy. I just had to endure it. A patient should not have to experience this nightmare with today's technology. The dr's listen to my concern, but don't do anything about it initially. I've experienced excruciating pain during my first c-section; numerous dental visits; recent colonoscopy; and breast biopsy last week. What can I do or say about this? Please help.

    Some patients who receive conscious/deep sedation for a procedure may experience discomfort. With conscious sedation or deep sedation, the surgeon needs to inject local anesthetic into the surgical site to prevent the patient from feeling any discomfort. Some patients may have some recollection from the local anesthetic being injected. Unfortunately, there are circumstances when "enough" local anesthetic cannot be given. If this is the case, the anesthetic plan may be changed to a general anesthetic. General anesthesia should provide complete loss of consciousness. While awareness during general anesthesia is a problem that we know exists, it is very rare. This may occur in spite of normal vital signs during the course of the procedure. Some medications, when used on a regular basis, may increase the requirement for anesthetic medications. Medication use should be discussed with the anesthesiologist involved with your case. For some procedures where conscious/deep sedation is suggested, it is not unreasonable for the patient to ask for general anesthesia to be performed.

    The anesthesiologist who is used by your surgeon should be consulted before the day of surgery so that proper attention can be given to a patient’s particular needs.

    I suffer shock from IV sedation and lose most of my hair within 3 weeks of surgery. The pain of that needle going in is just incredible. Is it possible that I am also allergic to Versed? How do I find a doctor or anesthesiologist who can sedate me painlessly, as with demerol and valium? I'm having an awfully hard time with this problem. Thank you.

    Your question includes several statements that may or may not be related. Your statement that you suffer from "shock" with IV sedation is difficult to interpret without knowing your medical history and reviewing the records from the anesthetics during which you had "shock". If indeed you do experience a severe life-threatening drop in your blood pressure simply due to sedative drugs then you may have a more serious underlying medical condition. Based on this statement it would be advisable for you to obtain copies of your anesthetic records and have them reviewed by your primary care physician to see if further medical work-up is warranted.

    Loss of hair after sedation or general anesthesia is probably much more common than is realized. The medical term for this is telogen effluvium. Briefly, due to a specific event, hair follicles prematurely terminate the anagen phase and enter the resting or telogen phase. The hair follicle is not damaged or diseased, but has simply had its biological clock reset. Resting hairs remain on the scalp for about 100 days, so hair loss occurs about 3 months after the event that caused the biological clock to be reset. Hair loss is diffuse and up to 50% of the body's hair can be affected. There are many types of events that can cause this to occur. They include acute blood loss, childbirth, high fever (commonly seen in children), and physical and/or psychological stress. Hair dressers, when they see patients who have had surgery, commonly blame this problem on the anesthesia. They are wrong-it's the surgery, because of the associated physical and/or psychological stress. Anesthesia itself does not cause this to occur.

    What needle are you referring to when you state that the pain is incredible? Is the act of starting an IV painful for you? If so, the nurse or physician starting the IV could use some local anesthetic at the IV site to minimize the pain. If you are referring to a needle being used during surgery to numb the area being operated on, then it is possible that your level of sedation may need to be increased so that you don't experience discomfort with the injections. Other rare causes of IV pain include infiltration (where the IV solution goes outside the vein into the surrounding tissues) and the use of propofol in a hand vein, which occasionally will result in a burning sensation.

    Demerol and valium are not necessarily superior to other drugs for comfort during surgery. Valium has been associated with pain during IV injection. Without knowing what the source of the pain is that you are referring to, it is difficult to answer your question. Please consult with your primary care physician, your surgeon and any future anesthesiologist that cares for you to address these concerns

    I have had 3 operations within 1 1/2 years. I am on dialysis, have a kidney transplant, and a hip replacement. My wife says that I have lost my memory. For instance, I don’t remember movies we saw, I don’t know where I put things, and I think my whole way of thinking is in slow motion. Could having that many operations in such a short time cause my memory loss?

    In a person with kidney failure receiving dialysis, it is the kidney problem, and the effects of the dialysis treatments, that are far more likely to cause memory problems than the anesthesia or surgery. If you have successfully had a transplant you will be taking immune suppression drugs that may also be affecting your mental function. Anesthesia medications are cleared from the body within hours, or at the most, days.

    Having said this, it is also true that the impact of anesthesia on recovery of brain function has become an important area of research. There are some who believe that general anesthesia can cause long term effects on memory in the elderly. But there is not a lot of evidence to support this conclusion, and the vast majority of people who undergo anesthesia and surgery recover their mental function quite soon afterwards.

    Is anesthesia the medicine that makes you sleep or does it reduce the pain?

    Anesthesia refers to the state of not feeling pain. It can be because the patient has been made unconscious (asleep), through the use of drugs (many of which are called "anesthetics") or because the area to be operated upon has been made insensitive to pain through the injection of local anesthetic drugs. In short, anesthesia is the state of being insensitive to pain; anesthetics are the drugs that create the insensitivity. The term "anesthesia" doesn't apply to a single agent or class of drugs

    A "local anesthetic" numbs the area where it is placed (like the dentist numbs the gums). Anesthetic agents that make the patient drowsy and relaxed (sedation) are the same drugs used in higher doses to cause unconsciousness for a general anesthetic. General anesthesia ("all the way asleep") always includes pain relieving medications, usually narcotics like morphine or fentanyl, as well as drugs to induce and maintain unconsciousness, achieved with a variety of intravenous medications (Propofol, Pentothal, Etomidate) and/or inhaled anesthetic gas (isoflurane, sevoflurane).

    Your anesthesia care team may use the word "anesthesia" to refer to the whole anesthesia care plan, whether the plan is local numbing medicine, sedation, numbing of a larger area (including spinal, epidural or arm/leg blocks), or a general anesthetic

    I wonder about anesthesia for hand surgery

    Anesthesia for hand surgery can be accomplished in a variety of ways, depending on the procedure (i.e., carpal tunnel release or tendon repair) and the surgeon and patient's preferences. Regional anesthesia (or a "block") involves numbing just the arm with injections of numbing medicine, either at the top of the shoulder (interscalene or infraclavicular block) or in the armpit (axillary block). If appropriate for the surgery, numbing medicine may also be administered in the vein (Bier block), at the elbow or wrist, or just at the area of incision and surgery ("local"). When any block is administered and used for surgery, sedation medicines are usually given intravenously (in an IV) to help you feel relaxed, comfortable and sleepy during the procedure. Use of a regional technique avoids the need for general anesthesia and a breathing tube in the windpipe (endotracheal intubation).

    The optimal choice for your anesthetic will be made before your next hand surgery when you discuss your concerns and preferences with your anesthesia team and surgeon.

    I have been told that I will be undergoing the TIVA sedation with a mix of several IV drugs. I am terrified that I will be aware or feeling anything during this procedure. Some of the drugs include: valium, a drying agent, a steroid, fentanyl, lorazepam and others that I cannot recall. I have been told that this will not be conscious sedation - it will be deeper. However, I will not be needing intubation, so it will not be general either. So, I know it will be deeper than conscious, and lighter than general. I have asked questions. They have answered - yet I am still confused. Could you please tell me if this is typically the type of thing that I will know what is going on - or awake? Thank-you in advance.

    TIVA stands for Total IntraVenous Anesthesia: all the medications you receive will be administered through an IV catheter and you will not receive anesthetic gas. The different levels of sedation ARE somewhat confusing and often leave patients wondering just what their experience will be.

    In the past, there was either "awake" in which a patient was aware and quite conscious, or "asleep", usually with a full anesthetic and intubation. Now there are many, many levels in between, states ranging from "happy, pleasant and relaxed" (light, "conscious" sedation in which a patient will readily respond to words or a light touch) to "snoozing away and not aware anything at all is happening" (deep sedation). At this deep level of sedation, the patient is breathing on her own, but is usually not responsive to talking or touch. Most commonly, there is no awareness at all or at most, slight recognition that there is some movement by the surgeon. For any dental procedure, there will still be a generous amount of local anesthetic injected into the gums, but unlike the dentist's office, you will not know when the injections are being done.

    All the drugs you mentioned are combined to give optimal sedation for the procedure and a comfortable recovery afterwards. The steroids prevent swelling and inflammation, the Valium (or Versed, from the same family of drugs) provides a very pleasant sedation and amnesia (unawareness), the fentanyl is for pain, and the drying agent decreases oral secretions. Another drug, Propofol, may be used to maintain a very pleasant asleep and dream-like state (patients often report very good dreams). You should only be aware of arriving in the operating room, monitors being applied and drifting off to sleep. You may drift in and out of vague awareness of being in the operating room (perhaps seeing the operating room lights or hearing the staff talking), but you should not experience pain or anxiety. Most patients awaken in the recovery room, feeling good, clear-headed and surprised that their procedure is over.

    Your concerns and fears are quite legitimate, so please do continue to discuss them with your surgeon and anesthesia team, especially on the day of surgery. Many of us have had quite unpleasant dental experiences in the past and those remembered fears often escalate as the time of surgery approaches. Planning and discussing an ideal anesthetic is the best thing you can do to deal with your apprehension!

    I am currently researching Ambulatory Care Centers and the current trend. I am attempting to show an advantage from a cost and earnings standpoint. Please provide references for articles that could support this. Thank you.

    While we could find no specific articles addressing your question, we do suggest that you consult medscape, pubmed, IMS Health, and PhRMA for supportive data.

    I am having a right inguinal hernia repair, without any type of complication. What type of anesthesia do you most recommend?

    We recommend a field block with local anesthetics for uncomplicated repair of an Inguinal Hernia. A field block will provide comfort throughout the entire surgery as well as provide postoperative pain relief. It is common for patients to also receive intravenous sedation along with the field block. Sedation will provide amnesia and prevent anxiety one may feel about being in the OR.

    Our daughter will have ear reconstructive surgery; our plastic surgeon stated the surgery can be performed in an out-patient surgery setting. Is pediatric surgery safe in this setting? Is there an accrediting agency that approves a facility for pediatric surgery?

    Many pediatric cases can be safely performed at an Outpatient Surgery Center, especially when they are minor procedures. Surgery Centers involved in pediatric surgery are usually equipped to handle many different levels of anesthesia for this population. In addition, centers which perform a high volume of pediatric cases may have an anesthesiologist who has had additional training in pediatric anesthesia. Other than agencies that accredit surgery centers in general, we are not aware of any specifically for pediatrics.

    What kind of operation is appropriate for ambulatory surgery?

    Appropriate procedures for ambulatory surgery are those associated with postoperative care that is easily managed at home, and with low rates of postoperative complications that require intensive physician or nursing management. Lists of ambulatory procedures quickly become outdated simply because they exclude certain procedures which in a short time may become routine in ambulatory settings. Length of surgery is not a criterion for ambulatory procedures because there is little relationship between length of anesthesia and recovery.

    Where does ambulatory anesthesia take place?

    Ambulatory surgery occurs in a variety of settings. Some centers are within a hospital or in a freestanding satellite facility that is either part of or independent of a hospital. Physicians' offices may also serve as locations for these procedures.

    What is the maximum length of surgery in the outpatient setting if sedation or and general anesthesia is used?

    There are no published guidelines concerning the maximum length of surgery that can be performed in the outpatient setting. Nor have there been any studies that have specifically addressed this issue.

    The decision to perform a procedure in the inpatient or outpatient setting has far more to do with the complexity, site and intensity of the surgical procedure than with the technique or duration of anesthesia. Patients may require inpatient admission because of the need for postoperative nursing, pain control,and monitoring for surgical complications, such as bleeding. Patients with complex or unstable medical conditions also require close postoperative monitoring and care, and may be unsuitable candidates for ambulatory surgery. During long procedures patients become increasingly uncomfortable because of the inability to change position, so that general anesthesia, rather than sedation may be more appropriate.

    Although modern anesthesia techniques are associated with shortened recovery time, patients still must remain in the outpatient facility for a period of time after their procedure. Other limitations may be the practical issue of how long an outpatient facility can stay open (staffing) and how late it can be reasonably accepted for a family member to take a patient home.

    What are some risks, besides death, of outpatient surgery?

    In general, the risk of a major complication in an otherwise healthy patient is extremely low, but not impossible. There is always the chance that a patient may have a reaction to a medicine, for example, that may not always be predicted. Sometimes this may be life-threatening, but this is the very reason that your physical status will be so closely monitored throughout the perioperative period. These "worst-case" scenarios include death, permanent or reversible neurologic injury, heart attack, among others. More common scenarios include nausea and vomiting, sore throat or hoarseness, dizziness, tiredness, headache, muscle aches, pain, etc, most of which are easily managed.

    I need to take narcotics because of pain. Is my risk of anesthesia increased?

    As for narcotic use, this most likely will not affect your anesthetic risk at all. It may make you more tolerant to the effects of narcotics that may be planned within your anesthetic, meaning that it may take additional pain medication to render you comfortable. The use of local or regional anesthetics may allow for easier and more thorough control of your pain.

    Are patients who are on medications for psychiatric diseases (e.g., bipolar disorder) appropriate for ambulatory surgery?

    These patients should consult preoperatively with the anesthesiologist, who will review their medical histories, medications, and planned procedures. In general, as long as patients are clinically stable on their medical regimens, they can be safe candidates for ambulatory surgery, and the risk of stopping medications may be greater than the anticipated risks of anesthesia in combination with the medicines. There may be exceptions to this, as with MAO inhibitors for depression. The consulting anesthesiologist will review these risks with each individual patient to plan the safest anesthetic. Your medicines may cause some side effects in combination with anesthetic medicines, but these may be anticipated and should not prevent you from having surgery on an outpatient basis.

    Should outpatient surgery be performed in very young children?

    Premature infants (gestation age < 37 weeks) who are younger than 50 weeks postconceptual age should not leave an ambulatory surgery center for at least 23 hours after a procedure because they are at risk of developing apnea (stopped breathing) even without a history of apnea.

    Is ambulatory surgery safe for very old individuals?

    Advanced age alone is not a reason to disallow surgery in an ambulatory setting. Age, however, does affect the pharmacokinetics of drugs: short acting drugs take a longer time to be excreted in older individuals. It is important to realize that most medical problems that older individuals may experience are not caused by age, but by specific organ dysfunction. For that reason, all individuals, whether young or old, deserve a careful preoperative history and physical examination by a physician.