Is there a maximum dose recommendation for versed? 

Not that I'm aware of. Versed, like most other anesthetic agents, is titrated to effect. In other words, you give some, as you assess the effect clinically and with monitoring equipment. Then you give some more if necessary. 

What is morphine made from? 

ﾠMorphine is extracted from the dried milky exudate of the unripe seed capsule of the opium poppy (Papaver somniferum). 

I am taking MS-Contin under a doctors care for chronic pain. Does this medicine interfere with novacain used in a dentist's office for a filling? If so what does a dentist use to numb the patients mouth? 

ﾠMS-Contin is a long-acting form of morphine, taken by mouth, which is often used for chronic pain conditions. 

Novocain is the trade name for the local anesthetic procaine. Procaine was one of the first local anesthetics developed, and the trade name has become synonymous with local anesthetics in general. 

Novocain, and other commonly used local anesthetics do not interfere with morphine. Pain killers may of course help to dull any dental pain that occurs after the dentist is done. You are unlikely to have a problem relating to your use of MS-Contin at the dentist`s office. 

I am allergic to ophthalmic neosynephrine. Do I need to worry about administration of this drug systemically? I believe it is used to increase blood pressure in emergency situations; might it be administered to me when I can`t advise of this allergy? 

Neosynephrine, also known as phenylephrine, is a drug that is commonly given by intravenous injection to treat low blood pressure during anesthesia. Phenylephrine eye drops are also widely used by ophthalmologists to dilate the pupil of the eye. 

Allergic reactions to phenylephrine eye drops can occur occasionally. These reactions can take the form of eye redness, swelling of the eyelids, redness of the skin around the eyes, and itching. This type of allergic reaction is called "contact dermatitis". 

Allergic reactions to intravenous phenylephrine are extremely rare. In someone who has a history of phenylephrine-related contact dermatitis, it may be impossible to predict whether a more serious, life-threatening allergic reaction (also called "anaphylaxis") might occur following the intravenous administration of phenylephrine. Allergists are the physicians best-trained to make an assessment of this problem and to perform further testing where appropriate. 

Your anesthesiologist should always be informed about your medication allergies or other adverse reactions to drugs. He or she will want to know the exact nature of the reaction you had, and the details of any allergy testing that may have been performed. With this information, the anesthesiologist is in a good position to make a judgement about avoiding the use of phenylephrine during your anesthetic. 

Any patient with a significant allergy is advised to carry this information at all times. Medic-Alert bracelets are useful - these are engraved with allergy or other health information helpful in case of a medical emergency. 

I did some cocaine last night and I am scheduled for back surgery tomorrow. I did a little more than half a gram. I will have lumbar surgery which requires general anesthesia. Is it possible something could happen to me. I do not do cocaine every day nor every week. I just got together with my friends and partied that night. 

After ingestion of cocaine 48 hrs is usually enough time to recover from any acute intoxicating effects of the drug. The more recent the use of cocaine, the more likely there are to be problems during a general anesthetic and major surgery. Cocaine does have potential long term effects on health of course, including the possibility of permanent heart damage, so any health practitioner will advise you to avoid it. You should be as forthright and honest as possible with your anesthesiologist about your recent drug use so that the right decision about whether to go ahead with your procedure is made, and any problems, such as blood pressure changes, or interactions with anesthetic drugs, can be anticipated. 

How long will it take for all of drugs used in major surgery to be complete cleared from the body? 

That's an interesting question. A full response would require the explanation of quite a few concepts in the science of pharmacology but I'll try to keep it brief! 

Pharmacokinetics is the study of what the body does to drugs and includes descriptions of how the body "distributes" and "eliminates" drugs. The pharmacokinetics of anesthetics drugs includes the study of drugs that are breathed in ("inhaled agents") and that of intravenous drugs, as well as drugs that are injected alongside peripheral nerves ("regional anesthesia") or the spinal cord or spinal nerve roots (spinal or epidural anesthesia). 

As you can see, we are talking about a variety of different drugs, administered in a variety of different ways. It is not possible to say, without being specific, how long the drugs will take to be cleared from the body. The effects of many anesthetic medications ends because the body "distributes" the drug away from the brain and into other parts of the body. Metabolism and excretion are the processes by which the drugs are "eliminated" or actually removed from the body. 

Aside from the properties of the individual drugs, the pharmacokinetics of anesthetic drugs depend on such things as age (which can slow the elimination of some drugs as much as two or threefold), genetics (which can have a similar effect), the health of organ systems (heart,kidneys, liver), and even the amount of protein, which binds some drugs, in the blood. 

In the case of inhaled anesthetics agents, elimination depends on how soluble the drugs are, heart function, and breathing. (By exhaling the drug you get rid of it). To give you an idea of the range of values, there are, at one extreme, drugs such as remifentanil, whose elimination half-life (the time taken for half the drug to be removed) is only a few minutes. There are also drugs with much much longer elimination times, such as fentanyl (elimination half-life 15 hours in the elderly, 4 hours in younger patients), valium (diazepam)(half-life 72 hrs) and thiopental (half-life up to 24 hrs). 

With modern general anesthetic agents such as propofol, remifentanil and desflurane almost all of the anesthetic agents can be gone from the body within a very short space of time, which is why outpatient anesthesia is possible. If other agents are used and you're not so healthy, and you need to be given strong medicines for postoperative pain relief, then its going to take a lot longer for the drugs to go and for you to recover fully from the anesthetic. 

How long after having pneumonia do you need to wait before receiving general anesthesia? 

ﾠAs is often the case in medicine, the answer to your question is "it depends!" It depends on the urgency of the procedure for which you need general anesthesia. It depends on how well you have recovered from the pneumonia. It depends on your general state of health. It depends on the type of surgery you need to have. It depends on whether you had lung disease before you got pneumonia. 

In most circumstances if you have recently had pneumonia, the ideal thing is to wait until complete recovery before having a general anesthetic. The time you need to recover will vary. Signs of recovery would be a normal temperature (no fever), no breathlessness, no cough or wheezing, a return of your white blood cell count to normal, the disappearance of any abnormal findings on your chest x-ray, and the return of a general sense of well-being including a healthy appetite. How long is that? A good rule of thumb is at least 6 weeks. Often, the chest x-ray takes longer to recover than the patient. 

Here are some reasons why having a general anesthetic when you have pneumonia, or are recovering from pneumonia, is not such a good idea. 

First, general anesthesia causes some of the small airways in the lungs to close, and this effect may be more pronounced, and less easy to reverse, if you've just had pneumonia. The closure of small airways means that the lungs are less efficient in picking up oxygen to supply to your body. In normal lungs the effects disappear within a few hours. If your lungs have been infected (pneumonia) this recovery process may not happen, and in fact you may get quite sick. If you are having surgery on your abdomen, or on the lungs themselves, the risk is much higher. 

Second, pneumonia or other types of lung infection may make the airways more irritable and prone to spasm, a bit like an acute asthma attack. 

Third, after pneumonia, the cells lining the air passages don't work so well doing their job of protecting the lungs, which involves whisking particles and bacteria out, killing bacteria with white blood cells, and so on. 

Pneumonia can sometimes be a very serious, even deadly illness. If you have had a very bad attack of pneumonia and were hospitalized or even on a ventilator, this is a very different situation than someone who had 'walking pneumonia' and had to miss a day or two of work. 

If your general state of health is excellent, and the surgery is very important or urgent, for example cancer surgery, it might be okay to have the general anesthetic sooner than 6 weeks after the episode of pneumonia. On the other hand, even if you've waited 6 weeks and all the symptoms and signs of your pneumonia have disappeared there may be some increased risk of lung problems with a general anesthetic. 

The most important thing is to consult your regular doctor(s) and your anesthesiologist before the surgery to discuss your specific circumstances and problems, and to be properly examined and appropriately tested (for example a chest x-ray and a measurement of your blood oxygen saturation). There is no easy answer to your question, but good medical judgment and care will help you through, hopefully without complications. 

Hi can you tell me if this is normal in an operation for a gallbladder removal, that these drugs are used brietal, scoline, pavulon, atropine, neostigmine if at the time no known muscle weakness , would be grateful for any information. 

An operation for gall bladder removal usually requires a general anesthetic.ﾠ During a normal general anesthetic, a variety of different anesthetic drugs are used.ﾠ There are drugs given into a vein (intravenous) that send you into an unconscious state or keep you in that state, inhaled anesthetic agents (gases) that also maintain unconsciousness, drugs used to relax (paralyzes) your muscles, drugs used to treat pain, drugs used to reverse the effects of the muscle relaxants, and drugs used to support your heart or blood pressure. 

The drugs you mention are all medicines used in general anesthesia.ﾠ Brietal is also known as methohexital and is an intravenous anesthetic agent.ﾠ Scoline (succinylcholine) and Pavulon (pancuronium) are both muscle relaxants.ﾠ Atropine and neostigmine are two drugs used together to reverse the effects of muscles relaxants at the end of surgery.ﾠ I am not sure what your concern is about muscle weakness.ﾠﾠ 

As noted, two of the drugs you mention are muscle relaxant, or paralyzing, drugs.ﾠ Some of the effects of these drugs can occasionally extend into the recovery period when patients are now awake, causing usually mild, but sometimes distressing muscle weakness. 

What is MAC-hour? How is it measured in practice? 

MAC stands for Minimal Alveolar Concentration. This is a measure of the amount of anesthetic gas needed to prevent movement in response to a surgical incision. A MAC-hour therefore, is the amount of anesthetic gas equivalent to 1 MAC given over 1 hour. The measurement of MAC-hours is usually done only in the context of research studies. To accurately measure number of MAC-hours given in practice, an automated anesthesia record keeper, plus an inhaled anesthetic gas analyzer are needed. 

In reading other questions, I can conclude that general anesthesia is one that puts you to sleep. Would that usually be administered intravenously? If asleep is general, what is laughing gas considered? 

ﾠGeneral anesthesia is a state of unconsciousness that can be induced by a variety of different drugs (anesthetic "agents"). Some anesthetic agents are administered by vein ("intravenously"). Sodium thiopental and propofol are examples of intravenous anesthetics. Other anesthetic agents are breathed in, or inhaled. Inhalational anesthetics include halothane, isoflurane and ether (no longer commonly used in North America). General anesthesia is not the same as the state of normal sleep, but is more like a "controlled coma", in which many of the body`s reflexes are suppressed (this is what permits surgery to be done) but vital functions such as breathing and heart function are also inhibited (this makes anesthetic agents inherently dangerous). Nitrous oxide (sometimes called "laughing gas") is an inhalational anesthetic agent. It is often used, always in combination with other agents, to induce general anesthesia. As a sole agent, nitrous oxide is commonly used in dental offices to provide analgesia (pain relief). When given in this way, the patient remains conscious, but somewhat indifferent to pain. A state of elevated mood can occur, hence the name. 

If you were a high risk surgery and had low resp rate shouldn`t you be kept on a monitor from surgery to recovery? Also if you had low resp rate should you be given more morphine? 

Respiration (breathing) should be monitored during recovery from surgery. Exactly how a person`s breathing is monitored, how frequently, and for how long will depend on several factors. These factors may include the patient`s age and general medical condition, the type of surgery, and the means of post-surgical pain control. Breathing can be monitored by simply counting the number of breaths per minute, or by more sophisticated electronic monitoring systems such as pulse oximetry. 

Morphine is a drug that is very commonly administered to control pain after major surgery. An unfortunate side-effect of morphine is the suppression of breathing. This is one reason why breathing is monitored after surgery and why oxygen is often given during the recovery period. A low respiratory rate may be a warning sign that too much morphine has been given. 

I noted two questions where patients asked about colonoscopy without sedation. It is possible - I had it done that way. I had a small dose of Demerol. I was fully awake and watched the entire procedure, which was very interesting. I do wish to state that there is discomfort - particularly as the scope followed the last corner of the colon and also from inflation used to open up the colon. The worst discomfort was somewhat intense, but brief. I would agree that there should be an IV so that if you say `Uncle` sedation can be quickly administered. Why did I do this? 1. I am a total techie and simply found the process and the technology very interesting. 2. I have never reacted well (mentally) to sedation. Two weeks after my colonoscopy I was having laparoscopic hernia repair which required general anesthesia. I did not want to have to deal with my own severe mental reaction from two back to back anesthesias - I could write a lot about that but that would be a separate question. My doctor was very understanding and worked with me the way a physician should. He said he does about 3 colonoscopies per month this way. He has also done upper GI endoscopies without sedation. I might add that assuming I am still healthy I am perfectly willing to go through this again although without sedation, although I might ask for a slightly higher dose of demerol. 

Thanks for your interesting comments which I think will be useful to other readers. I believe your desire to experience the colonoscopy while awake probably puts you in a small minority. But it's nice to know it can be done! The most pain comes when the bowel is inflated with gas and at the point where the scope must navigate around the "bend" - the splenic flexure. You described this well. Having an IV in place is like having a lifeline. If things are not going well with your chosen approach of minimal or no sedation then you can be "rescued" with pain-killing or sedative medication. As I've said before, it is important that you have a comfortable experience. It's also important not to lose sight of why you are having the procedure in the first place. The gastroenterologist is most likely to do a good job of examining your insides if you are quiet, immobile, and pain free! 

I recently had a colonoscopy. I was given a white milky medication via IV to sedate me for the proceedure. When I awoke a short time later in the recovery room, I felt GREAT. No side effects. I would like to know the name of the medication used. 

That's an easy one! The milky white medication is propofol (trade name Diprivan in its original formulation). Propofol has become, worldwide, the intravenous anesthetic agent of choice. When used for sedation, propofol often produces the experience you describe. A few individuals even have pleasant dreams. 

I am scheduled for a colon exam soon. I am currently taking Lortab and Soma for back pain. Will this affect me when given anesthesia? 

The short answer to your question is no. The Lortab and Soma you are taking for back pain will not affect your anesthesia. Lortab (acetaminophen plus hydrocodone) and Soma (carisoprodol) are commonly prescribed medicines for pain. Lortab is a moderately strong narcotic. Soma is a muscle relaxant. If you are not currently having any side-effects or other problems you could safely continue to take these medicines up to the time of your procedure. You should check with your doctor on the rules for eating, drinking, and medications before your particular procedure. In most cases, pain medicines can be continued, including the day of the procedure itself, when they may be taken with sips of water. 

I am having eye lid surgery in two weeks. Is it OK to take a 2mg of diazepam at 7:30AM and surgery then will be at 9AM. I have been told that I will be in twilight state, and that it was makes me nervous. they say I need to be somewhat awake to aid in the surgery. 

ﾠDiazepam, also known as Valium, is a medication that decreases anxiety. In larger doses (generally more than the 2 mg that you intend to take) diazepam causes sleepiness. If you are accustomed to taking diazepam for nervousness or anxiety it is unlikely that this will be a problem during your surgery. Hopefully it will help you get in a more relaxed frame of mind beforehand. During the procedure you will be given intravenous sedation (ﾓtwilight stateﾔ) to keep you nice and calm. This is usually very successful and safe, and allows a rapid recovery and return to daily life. The surgeon does not want you to be too sleepy however because you must be able to cooperate - for example by blinking - during the operation. You should always check with your doctor before taking any medication on the day of a surgical procedure. In most cases you will be advised to continue taking your usual medicines, but there are exceptions. In your particular case it is likely that your doctor will agree to letting you take the diazepam, but you should definitely check with him/her or the office to make sure. 

I have had several cystoscopies into the bladder and up into the kidneys for kidney stones and on one occasion had a stuck stone scraped off the ureter wall and a prostate biopsy which made the procedure last awhile; therefore, the question: In all cases, I was given conscious sedation with Versed and perhaps other agents. These agents seemed to be able to "put one to sleep" (or in a twilight) almost immediately and allowed the anethesiologist to awaken me almost immediately. For a medical procedure, this method seemed excellent since there was no pain or nasea and everything seemed to be short acting -- what a wonderful expreience. Now, for what types of procedures and to what *extremes* (more difficult procedures) can this method be used? Thanks! 

Thanks for your question! Iﾒll start by giving you the ﾓofficialﾔ definitions of four different levels of sedation. These definitions were created by the American Society of Anesthesiologists, and were recently adopted by the Joint Commission on the Accreditation of Health Care Organizations (JCAHO), the most important agency that accredits hospitals in the United States. 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 stimulation. The surgical procedures you describe (cystoscopy, removal of stones, prostate biopsy), if performed in an operating room, would usually require deep sedation or general anesthesia (levels three and four). The drugs that are used to provide minimal or moderate sedation are also used in many cases as part of the regimen for deep sedation and general anesthesia. Versed (midazolam) is one of the commonly used drugs. Propofol is another very useful agent. Higher doses of these drugs are obviously used to provide deeper levels of sedation and anesthesia. Modern anesthetic agents, given in a carefully measured fashion, with attentive monitoring, can provide patients with a relatively comfortable experience, with rapid onset, rapid awakening and a minimum of side-effects. This applies to all levels of sedation and anesthesia. The judgment about the most appropriate form of sedation or anesthesia for a particular surgical procedure is one best made by a qualified anesthesiologist, taking into account the needs of the surgeon and the preferences of the patient. 

I am having lacrimal duct surgery performed for a blocked tear duct. The surgeon is using monitored care anesthesia with sedatives. He said I would be very drowsy and possibly asleep. This is unclear to me. I would like to be prepared to ask the anesthesiologist a few questions regarding this type of anesthesia. Any light you can shed on the topic would be helpful. Will I need to be intubated? Will I be monitored? Is this type of anesthesia suitable for this surgery? What is the recovery like? Will I remember the procedure? How is the anesthesia administered? 

ﾠThe following detailed definition of "monitored anesthesia care" (MAC) is from the American Society of Anesthesiologists: "Monitored anesthesia care is a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure. Monitored anesthesia care includes all aspects of anesthesia care - a preprocedure visit, intraprocedure care and postprocedure anesthesia management. During monitored anesthesia care, the anesthesiologist or a member of the anesthesia care team provides a number of specific services, including but not limited to: monitoring of vital signs; maintenance of the patient`s airway and continual evaluation of vital functions; diagnosis and treatment of clinical problems which occur during the procedure; administration of sedatives, analgesics, hypnotics, anesthetic agents or other medications as necessary to ensure patient safety and comfort; provision of other medical services as needed to accomplish the safe completion of the procedure. Monitored anesthesia care often includes the administration of doses of medications for which the loss of normal protective reflexes or loss of consciousness is likely. Monitored anesthesia care refers to those clinical situations in which the patient remains able to protect the airway for the majority of the procedure. If, for an extended period of time, the patient is rendered unconscious and/or loses normal protective reflexes, then anesthesia care shall be considered a general anesthetic." The choice of a particular anesthetic technique (MAC, general anesthesia, regional anesthesia) is normally a decision made by the anesthesiologist, taking into account the type of surgery as well as the needs and preferences of both the patient and the surgeon. A monitored anesthesia care technique usually involves the administration of intravenous anesthetic drugs, oxygen (given with a nasal cannula or face mask), and standard patient monitoring procedures similar to those used during a general anesthetic. MAC implies that the trachea (windpipe) is not intubated. Because MAC usually entails the administration of lower doses of anesthetic drugs than with a general anesthetic, the recovery period tends to be shorter. The drugs that are used definitely affect one`s ability to remember the procedure, but periods of awareness can occur. Please consult your anesthesiologist before your surgery to establish what is planned for you and to answer any other specific questions. 

I am scheduled to outpatient surgery using an assisted local, what does that mean? I would much prefer to be put to sleep as I do not like needles. Thank you 

ﾠ"Assisted local" is not a term that I am familiar with but I will offer you an educated guess. "Local" usually refers to the use of local anesthetic as the primary form of anesthesia. An example is anesthesia for dental procedures, which is usually given by means of a needle to block the appropriate nerve(s). "Assisted" local may mean that an anesthesiologist has been asked to assist in your care. If this is the case, your anesthesiologist will monitor you during the procedure, and may provide additional anesthetic medications (intravenously or by mask) for your comfort, as well as perform a preoperative assessment and provide postoperative care during recovery. I suggest you check with your hospital or your surgeon to find out exactly what they mean by "assisted local". 

Because of severe post-op nausea and vomiting with prior surgeries, it has been recommended that I have a spinal with no sedation for an upcoming transvaginal sling surgery, and possible DNC. I have read some articles that say there are a number of times where the spinal "fails", i.e., does not provide pain relief. Is this common? I`m very nervous. Thank you for your help. 

It's not common, but does occur very occasionally. However, you can be sure that your surgeons will not commence the surgery unless the spinal anesthetic is really working. The days of the Civil War are over!! If it is not working, the spinal block can be repeated, orﾠyou can get a general anesthetic at that stage. If, as expected, your spinal anesthetic is successful, you may not need any sedation. However the majority of patients request, and are given, some form of intravenous sedation to achieve greater comfort. Minimal or moderate sedation with modern anesthetic and sedative agents like propofol and midazolam is very unlikely to make you nauseous after the surgery. 

My doctor and I have scheduled my c-section. I have one previous c-section, then a VBAC, and now I have opted for another c-section & tubal ligation. My previous C-sec was emergency and was done with an epidural. My doctor wants to perform this c-sec with BOTH an epidural AND a spinal. Is this necessary? Is this routine? What are the advantages to doing both vrs. one or the other? 

Decisions about your anesthetic are usually made together with your anesthesiologist, and with input from your surgeon. I am sure you will have an opportunity to talk with them about the different techniques prior to your C-section. 

The effects of spinal and epidural anesthetics are quite similar but there are certain differences. Your anesthesiologist may explain that a spinal anesthetic comes on more quickly than an epidural and produces a more "dense" block. Both movement and sensation are reduced in your trunk (abdomen, back) and legs. The increased degree of motor (movement) block is not really useful for a cesarean section. But the sensory block (numbness) means that you feel less of the pulling and tugging as the doctor delivers the baby and sews you up. 

With a spinal anesthetic the drop of blood pressure that is commonly seen with both types of anesthetic is usually more significant. The blood pressure drop, which sometimes is associated with an unpleasant feeling of nausea, is definitely unwanted but quite easy to reverse if it does occur. 

As you have realized, a combined spinal-epidural (CSE) anesthetic is not "necessary". However, in some centers it has become routine. Why? Well, because the spinal anesthetic comes on much quicker than an epidural, the anesthetic can be established within a few minutes and the surgery can commence very soon thereafter. With the CSE technique an epidural catheter is placed at the same time. The epidural catheter can then be used to "top-up" the anesthetic and, if left in place, can also be used to give you pain relief after your operation for a day or two. By contrast, with an epidural anesthetic the onset is much more gradual and it takes about 10 - 15 minutes to get the anesthetic established to the point where the surgery can begin. 

Advocates of CSE say you are getting the best of both worlds. You get the rapid, somewhat deeper, and perhaps more reliable anesthetic of a spinal, together with postoperative analgesia of the epidural. 

Are there any problems with this approach? CSE started to become popular about 10 years ago with the introduction of special needles that allow doctors to perform both types of anesthetic through a single needle. Since that time, clinical studies seem to show about the same rate of side-effects and rare complications as the single (spinal or epidural) procedure by itself. 

What is epidural anesthesia? 

ﾠEpidural anesthesia is a form of anesthesia in which a very narrow tube, (also called a catheter) is placed in the epidural space in your back. This space is within the spinal canal, but away from the spinal cord itself. Anesthetic medication is then injected into the space using the catheter. 

Epidural anesthesia temporarily blocks sensation, so that pain is not felt. Epidural anesthesia may also decrease the ability to move your legs, or even cause complete (but temporary) paralysis of your lower body. As the medication wears off, you will recover both sensation and movement. 

This form of anesthesia is useful for many types of surgical procedures on the lower extremity and the abdomen, including cesarean section, and orthopedic surgery on the knee or hip. 

Patients often ask whether they have to be awake for an epidural anesthetic. The answer, usually, is "not unless you wish to be!" Once the anesthetic is established your anesthesiologist will usually be happy to give you enough intravenous sedative medication to make you quite sleepy, and unaware of what`s going on. 

For insertion of an epidural, the adult patient is usually required to be awake, or just mildly sedated. This is because your cooperation enables the procedure to be performed safely and expeditiously. We will usually have the patient sit up, supported by an assistant, for the procedure. We also need to make sure that the anesthesia has reached an appropriate level before beginning the surgery and so will check that the anesthetic has taken effect (of course) before beginning the operation itself. 

hi thanks for answering my question on anesthetic drugs , the reason i am asking is because i am on Mestinon and have been for over 6 years but when i had operation i was not taking mestinon, hence my question on anesthetic drugs . thanks for answers. 

If you have myasthenia gravis, then there are some important issues if you have a general anesthetic. 

The main point is that patients with myasthenia, even when in remission, are usually very sensitive to muscle relaxants. That is, even a small dose of relaxant can have a profound and prolonged effect. Therefore, the dose, and timing of relaxant that is administered needs to be very carefully adjusted. In some cases it may be wise to avoid completely the use of muscle relaxants. 

If your myasthenia is severe, and you are having a big operation, the effect of the anesthesia and surgery in combination may be enough to affect breathing so that a period of mechanical ventilation (breathing machine) after the surgery is needed. Other factors that help predict the need for this treatment include having the myasthenia for several years, lung disease or breathing difficulty before the operation, and having to take large doses (750 mg or more) of Mestinon (pyridostigmine) per day. 

If you are taking Mestinon then it is usually continued before and after the operation. If you are unable to take anything by mouth after the operation, the Mestinon can be given intravenously, although it must be given in much smaller doses than the tablet form. Interestingly, the drug called neostigmine is in the same class as Mestinon. It is used routinely by anesthesiologists to reverse the effects of muscle relaxants. 

Thanks for your follow-up question. I hope this response was helpful. 

I was curious to know the effects of anesthesia on MG patients in remission. I heard that there is a possibility of a relapse. 

ﾠPatients with myasthenia gravis have a rare disorder of the nerve-muscle junction resulting in muscle weakness. In myasthenia the body produces antibodies to the nerve-muscle junction - this is one of the so-called "auto-immune" diseases. There is no evidence that I am aware of that anesthesia affects the disease process itself - i.e. that a "relapse," as you put it, occurs. However, a variety of surgical and anesthetic factors do come into play that may aggravate things and make the condition of patients with myasthenia gravis considerably worse. For example, muscle relaxant drugs are used routinely in anesthesia to make it possible to insert the breathing (endotracheal) tube and to keep the patient still during surgery. In patients with myasthenia, much smaller doses should, and are, used and yet these drugs may still produce residual effects making the patient profoundly weak after the anesthesia and surgery has ended. If the weakness is bad enough, the patient may be unable to breathe properly. One of the most common medications used to treat myasthenia, the "anticholinesterase" agents, may interact with certain muscle relaxants making them more difficult to reverse. Local anesthetic drugs such as lidocaine, and inhaled anesthetics ("gas") also have muscle relaxant properties which may cause weakness in a patient with severe myasthenia. Then there are non-anesthetic medications including certain antibiotics that also affect muscles and thus cause further problems. Patients undergoing non-emergency surgery should therefore be in the best possible condition beforehand, with their medications reviewed by an expert, and recommendations made for how to adjust them during the period before, during and after surgery. Other conditions that may be associated with the myasthenia, such as thyroid problems, or diabetes, should be attended to. In a patient with a severe form of the disease, plans may need to be made to keep the patient mechanically ventilated (breathing machine) in the ICU for some time after surgery. Special measures such as plasmapheresis, in which the blood is temporarily "cleansed" of antibiotics may be necessary. Despite the problems and issues Iﾒve described, it appears that most patients with myasthenia get through their anesthesia without major complications. Muscle relaxants can often be avoided entirely, and short-acting drugs used. If you have myasthenia, be sure to mention it to your surgeon and of course to your anesthesiologist. It is wise to arrange a preoperative consultation with your anesthesiologist when you can be carefully evaluated and appropriate plans made for controlled and safe anesthesia and postoperative care. Be sure to bring records of any previous procedures with you as these are a useful guide for all the doctors. 

I have checked in several resources and have gotten several different answers to this question. I am considering being an anesthesiologist and I was wondering how long an anesthesiologist goes to school. 

The answerﾠdepends on when you start counting the years! To become an anesthesiologist you must first go to medical school to become a medical doctor. In the United States, medical school is generally a four year course of study. To get your medical license, though,ﾠyou must first complete an internship - this takes another year. After internship, you must gain admission to a training program in anesthesiology. This is known as "residency"ﾠ - derived from the fact that doctors in this stage of training spend long hours in the hospital which almost becomes their place of residence!ﾠ (In fact, in the old days these doctors in training did live on the hospital premises.) ﾠ 

An anesthesiology residency program in the United States is three years - it is four years in Canada. At the end of this you are a "Board-Eligible" anesthesiologist - you must still pass two sets of exams - one oral and one written - before you areﾠ "Board-Certified" in the specialty of anesthesiology. Many anesthesiologists undertake further training in a sub-specialty. This is called "Fellowship." Anesthesiology sub-specialties include pain medicine, intensive care, and cardiothoracic anesthesia. 

Of course, to get into medical school in the first place you must finish high school and then get an undergraduate degree, usually, but not always, with a science focus. And get pretty good grades! Good luck with your decision and with school! 

Is there a standard NPO guideline for anesthesiologists to follow for adult and pediatric patients pre-procedure? If yes, please advise. 

"NPO" stands for "nil per os", which refers to the practice of limiting the intake of food and drink before anesthesia and surgery. To address this issue the American Society of Anesthesiologists (ASA) assembled a task force on "preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration". In October 1998 the ASA published practice guidelines, available at their website. The guidelines apply to healthy adult and pediatric patients undergoing elective surgery. The document is rather detailed but does contain the information you`re looking for. 

Many surgical procedures which formerly required hospitalization for a week or more are now being done as same day surgery. Obviously, some of this can be explained by new surgical techniques (laparoscopy and arthroscopy, for example) which result in smaller wounds, but even open surgery is being done on a one-day basis. The human body, per se, has not changed, so what has changed enough to account for such rapid discharge? I suspect that anesthesia and anesthesiology are largely responsible for the rapid growth of one-day surgery. Is that a valid assumption? If so, what is it about your field that lets patients be ready for discharge so soon? I recall having a relatively minor operation years ago under general anesthesia. I was in no condition to go home for 5 days, but now people go home after the same procedure in five hours! Can you enlighten us on this wonderful turn of events in surgery, in general, and anesthesiology in particular? 

Thanks for your interesting question. There are at least four reasons why hospital stays have shortened and so much surgery (60-65% or more) is today done on an outpatient basis. The last several years have seen tremendous pressures on healthcare providers to reduce costs. When hospitals began to be given a fixed amount of payment for most surgical procedures they looked at unnecessarily lengthy hospitalizations as one of the first targets for improving the bottom line. The second reason, as you point out, is the arrival of new surgical techniques such as minimally invasive (or so-called `keyhole`) surgery. The removal of the gall bladder used to require a 4 - 7 day admission to hospital, usually beginning the night before the procedure. We now routinely send our patients home after laparoscopic surgery just a few hours afterwards. There has also been a recognition that prolonged bed rest and immobilization after surgery is unnecessary and in fact slows the healing process and increases certain complications. So patients are encouraged to be up and about as soon as possible. Better techniques of post-surgery pain relief help in this area. And when patients do get home, they are offered various types of support, such as home nursing, to replace the care that would have been given in hospital. Finally, anesthesiologists can take credit for having introduced newer drugs and techniques, which hasten recovery. Modern day anesthetic agents shorten recovery times and are associated with fewer side effects, such as nausea, which would prevent a patient from going home. The safety of anesthesia has also improved greatly and we are more confident of sending even very elderly or medically complex patients home after a short recovery period without risking complications.