Iﾠam 29 years old and 35 weeks pregnant.ﾠI often have neck pain and dizziness due to wrong neck postures. These subside on rest on flat bed without pillow. My neck is short. OtherwiseﾠI am perfectly healthy. IfﾠI plan a caesarian, what would be better a spinal or general anaesthesia? 

Unless you have problems in the lower part of the spine I do not think your neck pain or dizziness will affect the decision about which type of anesthetic you should have for a cesarian section. However you should consult with your doctor to identify the cause of your symptoms. The evidence is rather compelling that regional anesthesia (that is spinal or epidural anesthesia) is the best option for routine, elective cesarian section. Among a variety of benefits for this approach, regional anesthesia: 1) Eliminates the transfer of anesthetic medication to the baby. 2) Avoids the potential for difficulty with airway insertion during a general anesthetic. 3) Allows the mother to be awake during the delivery in order to begin bonding with the baby as well as simply to enjoy the birth experience 

I am going in for achilles rupture surgery. We discussed anesthesia options. I asked if an epidural would be adequate. He mentioned they may be able to provide anesthesia from my knee down then said or a spinal. He didn`t elaborate much further on that knee down anesthesia. What is the name of that technique of anesthesia and do you think it would be adequate for my surgery. I just want the safest for the purpose. 

There are several anesthesia options for Achilles tendon surgery. An epidural can be used, but is sometimes not quite as effective as a spinal anesthetic, because the nerves supplying the ankle area (the sacral nerves) are a bit harder to reach with the epidural anesthetic solution. 

The sciatic and/or popliteal nerves can be blocked to provide a good anesthetic for ankle surgery. This is probably the technique that your surgeon was referring to. 

A general anesthetic is of course also an acceptable option for many. 

Finally, an intravenous regional block, or Bier block, involves the application and inflation of a blood pressure around the thigh, and the intravenous injection of local anesthetic. This is probably the least suitable anesthetic for any major ankle surgery. 

Which is the safest alternative? Well, anesthesiologists are obsessed with safety. If there was a clear, best, safest alternative we would all be doing it. But safety is related to many factors. One important factor is the health of the patient, including the medical conditions of that patient, allergies, medications, etc. Another factor is the skill of the anesthesiologist (and of course the surgeon). Any competent anesthesiologist should be able to provide you a safe general anesthetic unless you have some unusually severe medical conditions. Popliteal and sciatic nerve blocks require quite a bit of practice to guarantee a high level of success. There is an art to it which involves appreciating the anatomy and placing the needle in exactly the right spot to get nerve blockade (without injuring the nerve). Newer technology such as ultrasound guidance may help us all to improve in this area. The "systems" of care in the hospital and outside of it also contribute to safety - information and communication, equipment, the quality of nursing care, follow-up care, etc. 

The bottom line is that any of the techniques described above can provide you with safe, effective anesthesia for Achilles tendon repair. You are best off discussing the choice and coming to an agreement with your anesthesiologist and surgeon. 

Dear Sir, I am approaching you with great urgency. Time is of essence here. My mother requires immediate surgery for carotid-cavernous fistula but she has a history of severe allergy to certain types of local anasthesia, such as: Novocain 2 % +, Articain +-, Lidocain 10 % +-; Mepivocain +; Prilocain ++, Bupivacain + She has also been tested for preservatives with the following results: Methylbarben - ; Natr. Benz. +- ; Natr.metan. sulf +-. And also Hydrocortisonum + and Prednisolonum ++. NB all tests have been prick-tests. 

It has been suggested that tests could be done in small doses to determine if her body can tolerate other and/or newer kinds of local anaesthesia. Allergists consulted in my country are of the opinon that maybe it is possible to test for local anaesthetics but not likely for general anaesthetics. What is your experience with this? Do you agree or do you have some additional information that specialists here may not be aware of? What do you suggest could be done so that my mother could have this essential surgery performed on her? Surely there must be an answer to this problem! Some newer discoveries or alternatives so that people with such allergies are not denied the surgery that they need. 

It must be added that in 1967 she was diagnosed with hypothalamic deficiency with unclear etiology, which is expressed as asthenia, thermo-regulation disturbances and in vegetative dystonia with paroxysms. This diagnosis remains the same today. I would appreciate an answer to this question as soon as possible. As I said, the situation is very urgent and she is in terrible pain. Thanking you in advance for a quick reply. 

ﾠIt sounds like your surgeons have a preference for doing the surgery with local anesthesia. In North America this would be a bit unusual. Perhaps this is because of her other underlying problems. If their preference is for local anesthesia then it would be important to establish what type of reaction to local anesthetics have occurred. Was the reaction of minor consequence, and therefore the drug is still an option for use? Or was the reaction anaphylaxis (life-threatening) and therefore the drug is totally inappropriate for use in your mother? Skin tests do correlate with clinical reactions but the correlation is not always perfect. The positive skin test to hydrocortisone is quite surprising but may fit with the unusual hypothalamic condition. 

If the allergy to a particular agent is not of a life-threatening nature, it may be possible to go ahead with a particular local anesthetic agent, while "pre-treating" before administration, with steroids (other than hydrocortisone and prednisolone), and histamine-blocking medicines, to minimize any subsequent allergic reaction. Another observation is that it is unusual for people to be allergic to drugs from BOTH classes of local anesthetic (amides and esters). Usually it is one or the other. If the clinical reactions she has had are from drugs from one class, then choose an agent from the other, making sure that the preparation is also preservative free. So all of this needs to be explored with your allergist and other doctors. 

I am not familiar with all the considerations for this type of surgery but in all probability it is a procedure that can be performed with general anesthesia. This would get around the problem of multiple allergies to local anesthetics. Your mother's condition of hypothalamic deficiency and vegetative dystonia may make it more difficult to control blood pressure and muscle contraction during general anesthesia but these problems might not be insurmountable. 

Allergies to general anesthetic volatile agents, nitrous oxide, and narcotics, the three main ingredients of a general anesthetic, are rare. If local anesthetics are out of the question, then you are obliged to allow a general anesthetic to be performed. A vigilant anesthesiologist will be prepared to detect an allergic reaction quickly and to treat it effectively - the operating room is the ideal place for this type of careful monitoring and intensive treatment. 

I am needing a colonoscopy and another procedure they go down the throat I think it is a upper endoscopy, or maybe gastroscopy .....they told me since I can`t take demerol they are going to put me to sleep....I am scared to death ...can you tell me about this and is there any other options...thanks for your time. 

Please check this site for a range of questions and answers relating to anesthetic techniques and sedation. Sedation for endoscopic procedures, in skilled hands, has a very good safety record. You can undergo moderate or deep sedation for endoscopy with good results, minimal discomfort, remembering very little of the procedure, recovering quickly. 

I am scheduled to have bilateral bunion surgery. My orthopedic surgeon wants to do bilateral popliteal blocks for post-op pain control, although I will be having general anesthesia. The anesthesiologist expressed some concern about the blocks, saying that doing 2 at once is not common, and it could exceed the safe level of regional anesthetic agent used, causing "toxicity" to me. How dangerous is this? Can enough drug be used to achieve post-op anesthesia without causing systemic problems? Is a tourniquet used? In what way? All during surgery or just during the block? 

Thanks for your interesting question. Popliteal blocks are nerve blocks that provide anesthesia for surgery of the foot and ankle. They are also useful for postoperative (after surgery) pain relief. 

It is admirable that your orthopedic surgeon is offering you this intervention which should make your recovery from surgery much more comfortable. The benefit from such nerve blocks can last as long as 24 hours, and occasionally even longer. 

Ideally, any disagreement between your surgeon and anesthesiologist (who is likely to be the one performing the block(s)) about the best course of action can be resolved through discussion among all three of you. Like anything in medicine, there is a balance of risks and benefits, and you need to be fully informed about them. This is so that you, the ultimate decision-maker, can make the best decision (for you) based on adequate information. 

The only way to entirely avoid the risks of popliteal nerve block, which, (like any other nerve block), include infection, nerve injury, bleeding, and local anesthetic toxicity, is not to do it at all. But then you lose the benefit of excellent pain relief which may be difficult to obtain with any other method of analgesia. 

Local anesthetic toxicity refers to the risk of absorption into the bloodstream of local anesthetic, which can cause initial symptoms such as dizziness, ringing auditory sensations, and numbness around the face, leading on (rarely) to seizures and even cardiac arrest. Cardiac arrest, fortunately, is extremely uncommon, but given enough absorption of local anesthetic (examples: bupivacaine, ropivacaine) this can certainly occur, and is difficult to treat. The risk of such an event can be lowered by using a decreased concentration of the local anesthetic; in this case however you lose out on the duration of the analgesia you get, which will be proportionately shortened. 

The other complications to which I have referred are also uncommon. For various nerve blocks, especially those for anesthesia and analgesia of the shoulder, there is quite a lot of data showing that permanent nerve damage is very uncommon, probably less than 1 per 1000, but that quite a few people have mild nerve symptoms lasting up to a few weeks (often it is hard to distinguish between symptoms related to the nerve block, and features relating to the surgery itself). 

A few specifics about the popliteal block. Firstly, quite a lot of local anesthetic is used for an individual (unilateral) block. So your anesthesiologist's concern is appropriate. His or her primary concern, always, is for your safety. However, some experts, such as those at St Luke's Roosevelt Hospital in New York, assert that there is very little absorption from this site and consequently a rather low risk of toxicity. Secondly, the popliteal nerve block does provide enough anesthesia of the leg to facilitate the use of a tourniquet (an inflatable cuff wrapped around the limb to decrease the amount of blood in the limb beyond the cuff). This makes the surgery easier. The tourniquet would be applied after the nerve block is done and would be kept inflated until the end of the surgery. During prolonged surgery the tourniquet can become very uncomfortable even though the nerve block may have been effective. This would not be a problem if you are receiving a general anesthetic along with the popliteal nerve block. 

In summary, the decision of whether you should have bilateral (left and right) popliteal nerve blocks for your bunion surgery is best made in consultation with your surgeon and anesthesiologist, with full appreciation of the risks and benefits of the procedure. Good luck with your operation! 

I had two collapsed lungs nearly 5 years ago and I am going to have laparoscopy surgery done to remove an ovarian cyst and my appendix. I have heard nitrous oxide shouldn`t be used on me as a gas. Is it available intravenously? Are certain anesthesias bad or risky for my medical history? 

ﾠThanks for your interesting question. A collapsed lung, the condition also known as "pneumothorax," occurs when air enters the pleural space between the lung and the chest wall. The air either comes from a hole in the lung itself, or from the outside, penetrating through the chest wall. With the entry of air, the lung reduces in size and cannot perform its function, the transfer of oxygen and carbon dioxide. A small reduction in size can be tolerated without too much trouble, but a more significant collapse leads to real difficulty with breathing, and must be treated with a chest drainage tube that allows re-expansion of the lung. A pneumothorax can occur spontaneously or be the result of trauma to the chest. Spontaneous pneumothorax can be a sign of serious underlying lung disease, such as bronchiectasis, or emphysema. It can also occur in patients with other kinds of problems, such as Marfans syndrome, or can happen without any apparent lung disease. It would be important for your anesthesiologist to be aware of your history, including the circumstances of the pneumothoraces, the symptoms they caused, how they were treated, and whether you have underlying lung disease. A chest x-ray will probably be advised. Nitrous oxide is an anesthetic gas which can cause expansion of a closed gas-filled space - such as a pneumothorax. Although nitrous oxide is unlikely to cause a pneumothorax, if one happens to develop it may make things worse. For this reason it is an agent that your anesthesiologist might choose to avoid. Fortunately there are many other anesthetics that can be substituted. It will also be important for your anesthesiologist to be pay special attention to keeping the air pressure in your lungs on the low side during the anesthetic. The usual anesthetic technique for laparoscopic surgery involves placing a breathing tube and mechanically ventilating the lungs with a breathing machine or ventilator. High pressure may increase the chances of causing another pneumothorax. If this happens your anesthesiologist and the surgical team should be prepared to diagnose and treat the problem with a chest tube. It is possible however that treatment of your previous pneumothoraces with pleurodesis has dramatically reduced the chances of such a complication occurring anyway. This is one reason why it is important for you to bring as much information as you have about previous treatment to your meeting with the anesthesiologist, which should be scheduled well ahead of the surgery if possible. 

I am going to be having surgery on my right talus in January due to avascular necrosis. It is vital that I be functionally cognitive and alert very soon following the surgery -- it`s the first day of classes, and I have to be able to function for a law class. I would prefer a popliteal block with local to cover whatever isn`t taken care of through the block. 

I`m wondering about sedation -- can the anesthesiologist give me some type of medication so that if I hear "uh-oh" I don`t freak out and try to run from the OR with my foot sliced open, while keeping me alert enough (not necessarily completely functional throughout the surgery) so that I can see parts of the operation? 

If I tell my anesthesiologist that I`d prefer a popliteal block, will he/she look at me like I`m an idiot? Or, would I be better off to explain that I need to be functional and cognitive very quickly after the surgery? Any advice you can offer would be great! 

Iﾠhave requested to be awake during my foot surgery and my surgeon will honor my request. The anesthesiologist, however, says she personally is a `wus` and suggests I have `10 minutes` of propofol or alfentanyl while the ankle block is set up as it is very painful for the patient. Is this a good suggestion, and will I indeed be awake after `10 minutes` to not miss the experience? 

It is pretty standard to administer some combination of drugs (midazolam, propofol, alfentanil, fentanyl being the most popular in the US) to reduce or eliminate the pain associated with needle insertion for regional anesthesia. 

Both propofol and alfentanil are short-acting drugs. Alfentanil is an opioid, in the same class as morphine. It is a profound analgesic but like other opioids does have sedative properties also. Propofol is an intravenous anesthetic or sedative drug. That is, in lower doses it is sedative, and as the dose is increased consciousness is lost. 

It is certainly possible that propofol and alfentanil, alone or in combination, could give you a 10 minute period of analgesia and sedation after which you would be fairly wide awake, to "enjoy" your operation! Neither of these drugs provide a complete on-off experience; there is likely to be at least bit of residual sedation for a while after. Another drug with a very short duration of action is remifentanil, which has a half-life of only 3 or 4 minutes. This is also an opioid medication. 

An ankle block involves at least 4 separate injections of local anesthetic so it can be quite painful. There are 4 branches of the sciatic nerve that must be blocked, and sometimes an additional injection across the top of the foot. An additional factor to keep in mind is that some surgeons like to use a tourniquet during the operation to minimise bleeding. The tourniquet is placed around the thigh very tightly and can lead to a significant amount of discomfort. 

I need to have carpal tunnel release done on both hands; I have heard that it can be done without sedation (which I am scared to death of) with just some sort of "block", while others have told me that some sort of sedation must be addded.....I had a terrible reaction to "conscious sedation" before and could never do it again...........the pain is getting unbearable at night and the EMG/NCV tests have caused my doctor to refer me for surgery; which I would love to have if it can be done without sedation. Any help will be really appreciated. 

Carpal tunnel surgery can be done without sedation. Your surgeon can inject local anesthetic into the area as he works ("local"). Alternatively, an intravenous regional block ("Bier block") is very effective. Neither of these techniques require sedation, although in the majority of circumstances some sedation would be given to make the experience more comfortable. If you are sure you don't want the sedation it is likely that your anesthesiologist and surgeon will accommodate your request. 

I`m only 52, but I have BPH which has not responded to Avodart and Flomax...these worked for a year then I`m back to my usual up 5-6 times per night. I saw a urologist who said that I was a good candidate for PVP green light laser treatment......I would love to do it, but my concern is the anesthesia.......the video that I saw said "pudental" block or something like that plus painkillers; I just don`t want any "sedation" due to a previous bad experience with so called "conscious sedation".....is this reasonable? Any info will be geratly appreciated. Thanks 

It is possible to have prostate surgery with a local anesthetic block. Needles can be inserted via the lower abdomen (suprapubic area) and/or the perineum to reach the neurovascular bundle that supplies the prostate, or the pudendal nerve. I am not certain how effective this block is. It is not a block performed routinely by anesthesiologists. 

Prostate surgery is usually done with either spinal or general anesthesia, not the technique you mention. Perhaps your surgeon has a lot of experience with this technique. He would then be able to tell you how complete the anesthesia is, and how much discomfort you might expect. This in turn would affect how much, and what kind of sedation or pain-killing medication you would need in addition to the block. 

I was told to have a breast biopsy, but the doctor said it could not be done with a local anesthetic, but she would have to use MAC. I have multiple chemical sensitivity, and am allergic to many medications, as well as plastics, all contrast dyes, ester anesthetics, etc.etc. etc. I had a very negative reaction to Versed (severe brochospasms for over a month) following a colonoscopy in 2001. I would like to know which drugs are used in MAC. The doctor said it couldn`t be done with a local, because it`s "easier on the doctor" if the patient is not awake. Apparently, the patient`s allergies/sensitivities are not as important, but I have not found any other doctors in my area willing to do it with a local anymore. Thank you. 

MAC is not a specific medication, or set of medications. In fact, MAC (Monitored Anesthesia Care) is a difficult term to define (see previous questions on this topic) and refers to some level of sedation, accomplished usually with intravenous drugs, plus local anesthetic injected by the surgeon. Most "MAC" anesthetics in the United States probably involve some combination of propofol, midazolam (Versed) and fentanyl. However, there are other drugs that may be used, especially in other countries. 

Sedation can certainly be administered without the use of midazolam, and some people find that a propofol-only technique is well tolerated. A potent opioid like fentanyl is needed to "cover" discomfort that is not entirely blocked by the local anesthetic, limit the pain of injection of the local anesthetic itself, and to provide some degree of pain relief once the procedure is over. 

A recent article in the British Journal of Anaesthesia may be helpful. It suggests that in patients with your kinds of problems usual anesthetic practice should apply, while obviously avoiding drugs which you are known to be sensitive to. 

What is the difference between conscious sedation, MAC and LMAC. 

Thanks for your question. I am not familiar with the abbreviation "LMAC". "MAC" (Monitored Anesthesia Care) and "conscious sedation" are some of the many terms that have been applied to the various levels of sedation that can be achieved when general anesthesia is not required. These terms are poorly defined and are best replaced by the official terms, "mild sedation", "moderate sedation", and "deep sedation". For more information please refer to other answers on this site. 

What is the difference between MAC sedation and Conscious or Twilight sedation? Which is preferred for the above procedures? Are these two basically the same? 

The problem is that these terms - MAC (Monitored Anesthesia care), Conscious Sedation, and Twilight Sedation - are poorly defined. Although still in widespread use, the preferred way to describe the different levels, or "spectrum" of anesthesia is the following: 1. MINIMAL SEDATION (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. 2. MODERATE SEDATION (perhaps synonymous with 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. 3. DEEP SEDATION is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. 4. GENERAL ANESTHESIA is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. For a procedure like colonoscopy, the goals is usually to provide sedation at levels 2 or 3. However, this is not a mechanical process in which you can select an exact dose to give you an exact level of sedation. The level of sedation can and does vary between individuals getting the same doses of the same medication, and also in the same individual depending on the level of stimulation produced by the procedure. The practitioner administering the sedation must be able to "rescue" the patient who unintentionally progresses into a deeper level of sedation. 

I have an upcoming colonoscopy and was told that I have several choices as to the type of "anesthesia" that I can get....first was some sort of "conscious cocktail" of painkiller and amnesia drug that is usually effective,and a second, "deeper" drug "diprivan" administered by an anesthesia person and thirdly nothing at all. The doc says that choice one works well on "most people" but not on all, choice number two (the diprivan) is great but expensive, and choice three (nothing) is only the choice of a small percentage, but the "safest" option.....This is just a screening test due to bad history, no emergency...just from a safety standpoint, is there a significant difference of risk between the three choices? I`m scared to death of the idea of any anesthesia and am leaning towards nothing if the first two are at all risky. Thanks 

Thanks for your question. Your doctor has provided a not unreasonable summary of the choices except that he is not balancing risk against benefit. Options one and two are very safe in the hands of any well-trained clinician using appropriate monitoring and clinical judgment. Option three (no sedation at all) is the safest from the point of view of side-effects from anesthesia (obviously). But here's a question. Do you want the doctor to have the best possible chance of giving your colon a thorough going-over? I assume the answer is yes - else why bother having the colonoscopy? The best possible conditions for the doctor doing the colonoscopy are: 1. The patient is asleep (immobile and not wriggling around) 2. The endoscopist does all the time needed to complete the procedure with thoroughness There is at least one study showing that in patients who get the deep sedation technique, more polyps are found in the colon than those who get the usual "cocktail". There are certain parts of a colonoscopy, such as when the scope gets to an area called the splenic flexure, that can be really very uncomfortable. 

If I had surgery on my knee, can epidural anesthesia used for that, or is it only used for having a baby? I`ll wait for your answer. Thanks 

ﾠI think you already know the answer to your question! Epidural analgesia and anesthesia can be used for surgery on the lower extremities as well as for pelvic operations and for childbirth. It's a common choice for operations on the knee. 

Among the benefits are the avoidance of sore throat or dental injury from breathing tubes, the operation can be done with minimal or no sedation, rates of nausea are much less, and the patient is pain-free in the recovery period until the anesthesia wears off. Not everyone is a candidate for epidural anesthesia however. For outpatient surgery the home-ready recovery time tends to be a bit longer than for general anesthesia. Older men may experience difficulty with urination. A few patients (1% or less) develop headache. For a fuller discussion of risks and benefits that apply to you please check with your anesthesiologist. 

My wife is having a scheduled c-section (VBAC), and her doctor said she will need to undergo a spinal for her anesthetic. With our first, the c-section was done in an emergency, and she had an epidural. She had no headaches or side effects from the epidural. We have heard bad things about the spinal,often causing severe headaches, even migraines long after the birth. From what I`ve found, the spinal is preferred because it makes the procedure simpler for the docs and nurses. Can you tell me any reason why it would benefit her more, in terms of recovery, to go ahead with a spinal instead of an epidural? 

A spinal anesthetic involves the insertion of a needle, usually in the lumbar (low back) region, followed by the injection of a local anesthetic solution. The needle is then withdrawn, and the anesthetic effect occurs quite rapidly. Spinal anesthesia has been around for a long time, and is recognized as a safe and effective means of providing anesthesia for cesarean section. Because the onset of anesthesia is very rapid and reliable, some centers use spinal anesthesia routinely for elective c-sections. 

The alternative method, epidural anesthesia, tends to be a bit slower in onset, and may result in a slightly less "dense" block (that is, sensation is at the surgical site is not eliminated as completely as with a spinal anesthetic). 

Unfortunately, headache can occur after a spinal anesthetic and this may be a significant, though not a life-threatening problem. The headache, sometimes called a "spinal headache" is thought to be due to leakage of spinal fluid through the tiny rent in the membrane that is made by the spinal needle. The resulting drop in pressure of spinal fluid probably causes traction on the spinal membranes, resulting in pain. The pain usually occurs when the patient stands up, and disappears when lying down. 

A spinal headache can be treated with pain-killers and oral fluids. If these simple measure are not successful, an injection of the patient's own blood into the epidural space, in the same region as where the original spinal block was done, is amazingly effective at eliminating the headache. This technique is known as a blood patch. 

During the performance of an epidural anesthetic, the needle tip is placed in the epidural space, which lies just outside the membrane covering the spinal fluid. Occasionally, even in experienced hands, (perhaps 1 in 200 times), the needle can cause a small tear in the membrane itself. When this happens, a spinal headache can also occur. 

In our center, epidurals are used routinely, and very successfully, for the treatment of labor pain and also for c-sections. One benefit of epidural anesthesia for c-section is that the epidural can be left in place after surgery to treat the pain very effectively. A long-lasting pain medication (morphine) can be injected along with a spinal anesthetic, but the duration of pain relief is only about 12 - 24 hours. 

So, both spinal and epidural anesthesia can cause headache. And the incidence of spinal headache is about the same for both techniques. In the case of spinal anesthesia, the use of the tiniest needle possible, and the use of particular types of needle with rounded tips, is thought to reduce the incidence of headache. I would strongly suggest that in order to allay your fears you ask to discuss the anesthetic technique, its risks and benefits, with your anesthesiologist well ahead of the surgery. 

Female age 38, heart arrthymias: no meds (see electrophysiologist for annuals) heart healthy lifestyle, sensitivity to medications and deciding what and whom should perform surgery. Removal of lipoma (diagnosis by feel). Can`t have epi and during a local, and removal of pre cancerous lesion had cardiogenic syncope (tilt table positive). Low bp, heart murmurs, autonomic nervous system. What is least risky: Local/General/Sedation with a general or plastic surgeon? Thank you for your professional opinion. 

ﾠI cannot comment on whether a plastic or general surgeon would be the best choice. Also, I cannot say in your particular case what is the best or safest form of anesthesia. Local anesthesia can sometimes be a very difficult experience for surgeon and patient when the surgery is more extensive than first thought. Adding sedation can help, but uncontrolled sedation is sometimes much more risky than a controlled general anesthetic. In fact a decision between one or the other may not be necessary. You could start with local anesthesia plus mild or moderate sedation and see how it goes. At any sign of excessive discomfort or impending syncope, your anesthesiologist can change to general anesthesia. This does mean that your anesthesia provider is someone competent to assess the need for, and manage the transition. You don't explain why you cannot receive "epi" (epinephrine I presume). If this is indeed the case, your surgery may be more difficult because epinephrine helps reduce bleeding. Other vasoconstrictors are available however. If your surgeon insists that epinephrine be used, it may be best that you receive a general anesthetic so that unpleasant side-effects that may have troubled you before, such as increased heart rate, are not experienced. 

I am scheduled for gynecological surgery. I have been given the choice of a general anesthesia and a deep sedation. I am not clear about the state of awareness. I appreciate your input and expertise. 

Deep sedation and general anesthesia are part of a continuum. In other words, the one shades into the other. The same medicines can be used to produce deep sedation as general anesthesia. During general anesthesia a patient is unrousable, unconscious, lacking in recall. There is no awareness of events taking place around the person, including the surgical procedure. Some form of airway device is usually inserted because general anesthesia causes the airway muscles to lose their tone - they loosen up - and the airway may then become obstructed unless the anesthesiologist takes action to keep it open. During deep sedation insertion of an airway is usually, but not always, unnecessary. During deep sedation, there may be some mild depression of breathing whereas during general anesthesia breathing is definitely impaired, hence the need for extra oxygen and, sometimes, mechanical help with breathing. During deep sedation the blood pressure is usually okay, during general anesthesia a drop in blood pressure is a common feature. I hope this answers your question. 

Are there different types of anesthesia that can be used when having an endoscopy done? 

ﾠTheﾠchoices for anesthesia when having an endoscopy range from none, all the way to general anesthesia. It is well to keep in mind that ﾓendoscopyﾔ includes both fairly minor, short procedures, such as sigmoidoscopy (examination of the rectum and lowest part of the colon) and also much longer, more uncomfortable procedures such as ﾓERCPﾔ (endoscopic retrograde cholangiopancreatography). Among the most common procedures are gastroscopy (examination of the stomach and duodenum) and colonoscopy (looking at the entire length of the rectum and colon). Given the variety of endoscopies, as well as the variety of patients, the type of anesthesia will also vary. So, the type of anesthesia administered depends on the intensity and duration of the endoscopic procedure, the age of the patient (children usually need much more anesthesia than adults), the setting in which the procedure is done (e.g. doctorﾒs office vs. hospital clinic), the tolerance for discomfort of the individual patient, the skill of the practitioner giving the anesthesia, and, not least, the speed and skill of the endoscopist. In addition some patients have medical conditions that make specialized anesthesia care, including general anesthesia with a breathing tube, necessary. In most cases, general anesthesia is unnecessary, and various endoscopies are done with a combination of local anesthesia (sprayed in the throat, in the case of a gastroscopy, for example), with intravenous sedation. A variety of different drugs are used for this purpose. This sedation should be accompanied by standard monitors of breathing, blood pressure, oxygen levels, and so on. If you are concerned about the discomfort of an endoscopy rest assured that with appropriate anesthesia care you should be able to have a safe and relatively pleasant experience. 

Dear Doctor, This is an urgent question as I plan to have a mastectomy in a few days. Does a mastectomy require local, regional or general anesthesia? Does general anesthesia decrease the immune system during the surgery? Is there a way to decrease immunosupression caused by the anesthesia during and after surgery? (i.e. type of anesthesia, adding other fluids, etc...) Thank you for your help. 

Thanks for your very interesting questions. Please keep in mind that this is not an emergency service, and your questions should be discussed with your medical team as soon as possible, preferably well before your operation. 

A mastectomy is major surgery and almost always requires general anesthesia. Having said this, I will tell you that modern ideas about optimal anesthesia and pain management have led to the common practice of supplementing general anesthesia with local anesthesia or different regional anesthesia techniques. The regional anesthetic can be something as simple as injecting local anesthetic into the surgical incision site before, during, or after completion of the surgical procedure, or can be as complex as combining epidural or different nerve plexus blocks with the general anesthetic. The exact approach, its benefits, and risks, depend very strongly on the type of surgical procedure, as well as patient factors, and the expertise of the doctors. They are the ones in the best position to decide on the particular anesthetic you receive. 

In the case of a mastectomy, one option that has been described, but is probably not very commonly used, is paravertebral block, in which multiple injections are made in the back to block some of the intercostal nerves and related nerve fibers. This can decrease the amount of general anesthesia necessary as well as provide good pain relieve for several hours after the operation. Like any medical procedure of course it is not without its own risks (discuss with your doctors). 

On the second issue, there is certainly laboratory evidence that many anesthetic agents can decrease the function of some immune cells. Whether this effect translates into any difference in survival or cure rates of cancer is a totally different question. 

A recent retrospective study suggests that patients who have had a paravertebral block actually had better survival from breast cancer than those who had general anesthesia and usual pain treatment with opioids. This rather remarkable finding has prompted a large prospective, randomised controlled study (the strongest form of trial design) to answer the question of whether paravertebral block or epidural block increases survival from breast cancer compared to general anesthesia and opioid (morphine-like) analgesia. The results are eagerly awaited. 

At the moment I don't think we can say that any particular general anesthetic is better or worse than others in this respect. Although immune effects are present, presumably of only a temporary nature, anesthetics also suppress, to a greater or lesser degree, the body's stress responseﾔ to major surgery. In this case, suppressing the bodyﾒs response is thought to be beneficial, and may hasten recovery from surgery and restoration of function. 

What is not often realized by our patients is that anesthesia is a far more complicated undertaking than just injecting or breathing a few drugs and then waiting for the patient to "wake up". It includes attention to many of the issues I've already mentioned, as well as things you've noted, like administering the appropriate type and quantity of fluid, maintaining heart, kidney and lung function, protecting the body from its own potentially harmful responses to the surgical injury, preventing infection, excessive bleeding or blood clots, and providing or initiating adequate pain relief after the operation. 

I am going to get my wisdom teeth pulled out. I want to know if it`s better to take all four of them out at the same time or take them two at a time? I also want to know which is better local anesthesia or mild sedative? 

Your question about how many teeth it is best to have pulled out is outside my area of expertise. I suggest you check on this with your dentist. Removal of teeth is usually done in a dentist`s office, using local anesthesia. Your dentist may first apply a "topical" anesthetic medication to the tissues in the mouth. This numbs up an area in the mouth where the dentist will then inject a local anesthetic to block a nerve and prevent pain in the specific area of the mouth where the wisdom teeth are located. Some dentists will give you sedative medication to make the experience of tooth extraction more tolerable. Anti-anxiety medications can be used along with the local anesthetic methods described above. These sedatives can be given by mouth, inhalation, or intravenous injection. More complex dental treatments may require deeper levels of sedation, or even a full general anesthetic (unconsciousness). Please check with your dentist to decide which anesthetic technique is best for you. This will depend, among other factors, on the expected difficulty of the procedure, your degree of anxiety, and other medical conditions you may have. 

I am scheduled for an ACL reconstruction surgery. I have been given the choice of a general anesthesia or a regional anesthesia (conscious sedation, twilight state). I am not clear about the state of awareness which is involved with the twilight state. Would I be aware of my surroundings, sounds, smells etc. in a conscious sedation or would I be asleep. This is a 2-3 hour procedure and I do not want to be awake, however I am apprehensive about the side effects which can incur with a general, with intubation, nausea, etc. Also, if I have a regional and have a panic attack, is the option open to have a general half way through the procudre, or would I be given additional meds to sedate me? I appreciate your input and expertise. 

Thanks for your question. As you indicated, ACL reconstruction can be done under general anesthesia, or with what is known as ﾓregional anesthesiaﾔ. Regional anesthesia, in the case of a knee operation, is usually either an epidural or spinal anesthetic. In our center femoral nerve blocks are also used to provide an extended period of pain relief after the surgery. Most of our patients receiving regional anesthesia are given intravenous sedative medications to produce what some people call a ﾓtwilight stateﾔ. This is a state somewhere between wakefulness and complete unconsciousness. Official definitions and terminology are given below. This state is somewhat similar to normal sleep, although individuals rarely dream. Because levels of wakefulness vary, you may not be in a sleep state throughout, and may be aware of certain activities going on at some times. Your anesthesiologist can attempt to minimize these periods of wakefulness, especially if you discuss your concerns with him or her before the surgery. A small minority of patients ask us to be allowed to stay fully awake during ACL reconstruction. Some people even want to watch the procedure, and in fact it is possible for the patient to see some of what the surgeon does on television-type monitors. By contrast the vast majority of patients in our practice who elect regional anesthesia are not this adventurous, and request to be asleep enough to be unaware of their surroundings. This is fairly easily accomplished with modern anesthetic agents such propofol, which allow for rapid adjustment of sedation level, and rapid awakening after the agent is discontinued. As you note, a twilight state in combination with regional anesthesia means that intubation (breathing tube insertion) is not necessary, and there is not much risk of nausea during recovery from the operation. If you are someone who is susceptible to panic attacks you should definitely mention this to your anesthesiologist. If you become uncomfortable or anxious during the surgical procedure, you can certainly be given more sedative medication. There is a continuous process of adjusting the dose and monitoring the response anyway. If general anesthesia really becomes necessary (this is unlikely), additional anesthetic agents will again be given, and the anesthesiologist may decide to insert a breathing tube. I hope you have a pleasant experience with your anesthetic and a good outcome from surgery! Levels of Sedation: 1. Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. 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. 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. 4. Anesthesia consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful st imulation.