I am scheduled for two consecutive days of procedures, both requiring "conscious sedation". The first is a colonoscopy, and day two is a hysteroscopy, D & C and endometrial ablation (at our local hospital, but outpatient.) The gyn is aware of this schedule and is not concerned. Should I reconsider this schedule? If it`s safe I`d like to keep both appointments. 

whataquestion 

It's a pity you can't have both procedures on the same day, in the same facility, with the same anesthetic. This would be more convenient for you and probably less costly. 

I don't think there is a safetyﾠissue however. Assuming you are an otherwiseﾠhealthy person, having two procedures on successive days should not be a significant problem. Both the planned procedures are relatively minor and you would be expected to recover fairly quickly if modern anesthetic drugs are used by skilled practitioners. Don't forget to tell your anesthesiologist (or other anesthesia provider) who is taking care of you for the GYN procedure that you had the colonoscopy the day before and how it went. 

Good luck and let's hope you don't need any more procedures the rest of the week! 

I had surgery 4 weeks ago and it took over 6 attempts to place the IV in, I had no problem with the final spot he found but on the back of my right hand (where he tried twice) I swear it feels like a piece of cannula is left inside the vein. If I pull the skin on the base of my hand near the wrist I can feel a distinctive pull sensation up through the vein. If I brush the back of my hand by the knuckle again a get a strange sensation down that vein and if I try to place a finger on the base of the vein and pull down it feels like I am pulling at something. Is it possible when the cannula was inserted to set up the IV that the piece got severed somehow and was left inside the vein?? 

It is possible to leave a piece of the IV cannula inside the vein. Although possible, this is presumably a very rare occurrence. One way it can happen is if the person placing the IV withdraws the needle part and then reinserts it through the teflon cannula. In the process, the tip of the cannula can be sheared off by the needle. The plastic bit can then travel up the vein - this is called an embolus - and can theoretically go all the way to the heart. 

A more likely possibility is that you have some venous irritation from the IV cannula. Is there any tenderness over the vein? Is there any lumpiness or hardness over the vein? These are signs of phlebitis or thrombophlebitis, which are much more common complications of IV cannula placement. This type of problem normally resolves over a few weeks. I would look out for any signs of inflammation (warmth, redness, pain, swelling, tenderness) - these should be signs that you need to seek medical attention. If none of these are present then hopefully the unusual sensations you described will disappear without treatment over the next couple of weeks. If not, you should consider seeing a vascular surgeon. 

What type of source is the morphine drug. Is it a plant, mineral, animal, or synthetic? 

Morphine is derived from a flowering plant - the opium poppy, scientific name Papaver somniferum. It was first isolated in 1803! 

How can I find out the types of Anesthesias I am allergic to and what kind of test need to be made? 

ﾠJudging by the way you have posed your question, I am guessing that you may previously have had a reaction to an anesthetic. In that case, I need a little more information about the type of reaction that occurred and the circumstances. If you have not had a problem, and are not known to have any other type of allergy, it is most unlikely that you will have a serious reaction to any of the commonly used anesthetic agents. Testing for allergy to anesthetic drugs is quite specialized and should be undertaken by an experienced allergist. The tests involve either blood analysis or application of small amounts of the suspected allergen to the skin. 

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`m doing a research paper on the effects of anesthesia on a baby when it is administered to the mother during childbirth. What are the risks, how serious are they, and what are the chances of a negative effect on the baby. 

ﾠIn the United States, epidural analgesia is the most effective form of pain relief offered to mothers during labor and childbirth. It is considered to be very safe, both for mother and baby. In many hospital-based birthing centers, 70% or more of the women giving birth receive epidural analgesia or anesthesia. I will clarify the words used here. "Analgesia" is another word for pain relief. "Anesthesia" is the term for drugs or techniques used to block the pain of a surgical procedure such as a cesarean section. For a cesarean section, epidural or spinal anesthesia is safer than general anesthesia. If you need a more detailed account of the risks, and effects of these techniques, please be a little more specific about the kind of anesthesia you are researching in your paper. 

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. 

My daughter does not sweat and has had to be removed from all sports activities at school. She is eleven years old and has epilepsy, neurofibromatosis which the MD feels is mild, is on several meds for seizures, but still has seizures. She also did not sweat normally prior to being on the seizure meds. My question is she is going to have a vagus nerve stimulator placed next week, with her inability to sweat is she predisposed to malignant hyperthermia? 

Thank you for your question. Your daughter has complex problems that must be very challenging for both of you to deal with. Your daughterﾒs inability to sweat is, as you know, a significant problem because sweating is one of the important ways of regulating body temperature. People who are unable to sweat are therefore at risk for heat stroke. It is not clear from your question what is the actual cause of your daughterﾒs anhidrosis or hypohidrosis. Epilepsy drugs are apparently one potential cause of this unusual problem. I wonder whether neurofibromatosis could be associated with changes in autonomic nervous function (the autonomic nervous system controls the function of glands, including sweat glands) which can impair sweating. You should ask your neurologist about this. Malignant hyperthermia, the other disorder you refer to, is a specific inherited disorder, in which certain anesthetic drugs trigger a dramatic increase in muscle metabolism. One of the signs of this uncontrolled increased metabolism is a raised body temperature (hence the term ﾓhyperthermiaﾔ). Other signs are increased heart rate, rapid breathing, and eventually muscle stiffness (rigidity). Malignant hyperthermia is associated with severe metabolic disturbances that if untreated very often lead to death (hence the description ﾓmalignantﾔ). Fortunately, malignant hyperthermia, is both rare, and if recognized early, treatable. The treatment is to stop the administration of the anesthetic agents responsible, and give a drug called dantrolene. Affected persons can receive a safe anesthetic by avoiding so-called inhalational anesthetic agents, such as isoflurane, sevoflurane and desflurane, and muscle relaxants like the drug succinylcholine. The implantation of a vagus nerve stimulatorﾠis a new way to treat epilepsy. Although we do not yet have any experience with this procedure in our center, I imagine that this will require a general anesthetic. Most patients do not sweat under general anesthesia. In fact, most patients in the operating room cool down, and have to be actively warmed, using methods such as the application of special warming blankets. In summary then, malignant hyperthermia is a distinct disorder which is unlikely to affect your daughter. She is more likely to cool off than heat up in the operating room. Her temperature should, however, be carefully monitored during the anesthesia and, especially, during the recovery period. Be sure to discuss your concerns with the anesthesiologist responsible for taking care of your daughter. If possible you should go over these issues with him or her well ahead of the date of the procedure.ﾠ 

What of the side effects of anesthesia? Is it possible to cause anxiety or nervousness after having 2 surgeries in a 6 month period? 

It is unlikely that anxiety or nervousness would be due to any lingering effects of anesthesia. In other words, the medications used in anesthesia do not persist very long in the body and are usually almost undetectable within 24 hours. The psychological effects of both anesthesia and surgery, like any stressful experience, can, on the other hand, have prolonged effects. This would be especially true if either the anesthesia or the surgery itself did not go well. Did you experience any complications? Anxiety, nervousness and stress are common in our society and have many causes, both biological, psychological, and social. If your symptoms are severe, I would advise you to consult your family physician to look into this as soon as possible. However, I would also reassure you once again that the anesthesia is very unlikely to have any persisting effect to explain the feelings you describe. 

I had surgery 5 weeks ago on left knee. After 1 week had bad numbness in right knee. After 3 weeks had pins needles plus numbness. After 5 weeks it`s very painful, numbness, very bad pins needles. Also very bad muscle spasm. When I get out of bed there`s a very bad sharp pain like somebody is cutting me with a razor blade and it burns. 

ﾠFrom the title of your question I understand that you had your arthroscopy done under spinal block. You are concerned that your recent symptoms - pain, pins and needles, and muscle spasms - could be related to the spinal anesthesia. This is obviously causing you a great deal of pain so you should seek medical attention. You need to see your doctor as soon as possible to get a proper diagnosis. It sounds like you had a week or so in which you did not have any of the symptoms you describe. A nerve injury related to spinal blockade would be unlikely to present in the way you describe. A direct injury to nerves from needle insertion would be apparent soon after the anesthetic wore off. Later complications can occur - these include meningitis, hematoma (blood clot), and thrombosis (clotting) of arteries supplying the nerves or spinal cord. However the symptoms you describe are not typical of these serious problems, and could be linked to other diagnoses, including arthritis in the knee, spinal disc herniation, and the use of crutches, among others. 

I have had two major surgeries in the past 4 years and after each I experienced slow heart rate and abnormal heart rhythm... cardio consults for each only indicated it was related to the anesthetic. Is this a common occurence? 

Bradycardia is the medical term for slow heart rate. A normal heart rate is usually somewhere between 60 and 90 beats per minute. A slower heart rate is sometimes a sign of good health. Many highly trained athletes have slow heart rates, as low as 35 beats per minute. So, bradycardia is not a bad thing provided your blood pressure is okay, your cardiac (heart) output is normal, and the heart rhythm is normal. A normal heart rhythm is called "sinus" rhythm. Under normal circumstances the part of the heart that controls the rate at which the heart beats is the "sino-atrial node" (the sinus), hence "sinus" rhythm. After an anesthetic and surgery, a higher than normal heart rate is common, for a variety of reasons, including pain or discomfort. Bradycardia can also occur. The reasons for bradycardiaﾠinclude the lingering effect of certain drugs used in the anesthetic, including pain medicines like morphine or fentanyl, drugs used to reverse the muscle relaxants, and drugs used intentionally to slow the heart, like beta-blockers. If the rhythm is sinus, the blood pressure is normal, and there aren't any signs of low cardiac output, then bradycardia is not usually a cause for concern. 

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. 

Method of administration anesthesia drugs for sedation in dental procedure 

Sedation for dental procedures is often administered intravenously (IV). A small intravenous line is placed in your hand or arm before the procedure begins. The IV remains in place until the end of the procedure. Usually you will also be given oxygen and possibly nitrous oxide (`laughing gas`) through a nasal mask. The medications used are short acting to enable rapid recovery. 

I`ve had two surgeries this year, and in the recovery room I acted like a lunatic. Why did I act this way? It was totally out of character for me. 

Iﾒm not sure exactly what you mean by acting ﾓlike a lunaticﾔ! Itﾒs a very descriptive term, but I canﾒt be sure what it is that you actually did! My guess is that your behavior would have fallen in the category of ﾓpostoperative agitationﾔ. Sometimes an otherwise normal person, during emergence from anesthesia, will become physically combative, uncooperative, and unable to comprehend where they are, or what has happened to them. Such patients may prevent the staff in the recovery room from taking proper care of them, possibly endangering themselves or others in their immediate environment. Why would you act in this way? There are a variety of possible causes for this kind of agitation. The staff in the recovery room will first look for life-threatening causes, such as inadequate breathing, or circulation. A more common cause is simply pain, usually from the site of the surgery. Another frequent cause is a full bladder causing a desperate but unexpressed need to urinate! Trained staff will also look for other problems that might have to do with fever or low body temperature, metabolic problems, drug withdrawal (the stopping of prescription drugs or alcohol) or drug interactions (the effects of different drugs or medications taken together). Sometimes there is no apparent cause for this type of behavior, and it may be due to the lingering effects of any of the several different drugs that are given during a typical general anesthetic. Some people do seem to be particularly susceptible to postoperative agitation. We can speculate that a personﾒs emotional state before the surgery may have an effect on recovery. Anesthesia drugs can cause ﾓdisinhibitionﾔ, in other words they remove the usual restraints on behavior. A patient with unusually high levels of emotional distress or anxiety before surgery may be prone to agitated behavior during recovery. Interestingly, most patients seem to have little or no recollection of what occurred. 

Do you allow your patients to take diuretics the morning of surgery? Is there literature to support either taking or not taking the diuretic? How long prior to surgery where you want a patients PT/INR to be normal do you have them stop coumadin? 

This is a forum for questions submitted by patient, not clinicians. I suspect you are a clinician, so I would normally suggest that you to try to get your question answered in some other way. However, I believe a few general comments about this issue may have some value to the lay public so I will try to address it. Diuretics ("water pills") are commonly used to treat high blood pressure but are also given to patients with heart failure, or to treat swelling of the legs (edema). They are very useful medications, but they cause at least two problems when taken on the day of a surgical procedure. Firstly the need to urinate after taking a diuretic may be an inconvenience for patients travelling in by car. Secondly, and perhaps more importantly, diuretics may cause a decrease in blood volume ("hypovolemia") which can be detrimental during and after surgery and anesthesia, especially if the surgical procedure is a major one. So, under most circumstances, we tell our patients not to take their diuretics on the day of surgery. There are always exceptions to any guideline like this and patients should consult with their internist, surgeon, or (ideally) their anesthesiology about which medicines to take or withold on the day of surgery. The same advice applies to deciding when (or whether) to stop taking coumadin, a potent anticoagulant (blood thining) medication - check with your doctor(s). Our usual practice is to have patients stop taking their coumadin four or five days before the procedure, and checking the PT/INR (a measure of how thin the blood is) by drawing blood on admission to the hospital or surgery center. 

I`ve recently been experiencing a great deal of hair loss. First, this summer, specific circles of alopecia which seemed stress-related and responded to cortisone injections. Now I`m having more general loss and thinning - handfuls of hair when shampooing and otherwise. I was told this could be related to anesthesia from two foot surgeries (May and August). If so, when should this cease? Should I be concerned about other potential causes? 

One form of hair loss after surgery is related to prolonged pressure over a particular area of the scalp, causing localized loss of hair in just that area. This is called pressure alopecia. It is rather uncommon, but is known to occur occasionally after very long surgical procedures (many hours) where the head is kept in one position. It can also happen in special circumstances, such as heart surgery, where blood flow throughout the body, including the scalp, may be decreased. A different kind of hair loss is caused by various kinds of acute stress, which can lead to generalized hair loss all over the scalp. This form of alopecia is known as telogen effluvium. Causes include acute illness (e.g. severe infection, major surgery and severe trauma), chronic illness (e.g. cancer, liver or kidney disease), hormones (e.g. pregnancy, underactive thyroid), changes in diet, and a large variety of medications. Although some people believe that anesthesia itself can cause hair loss, I could find no evidence linking any of the commonly used anesthesia medications to this problem. In fact, some anesthetic techniques, such as regional anesthesia, are shown to actually decrease the bodyﾒs so-called stress response. However the stress of surgery itself is known to be a factor. And the recovery from surgery may be prolonged and stressful also. Be assured that future anesthetics are unlikely to contribute to your problem but be sure also to consult your physician for appropriate treatment and to rule out other causes of hair loss.ﾠ 

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. 

Why do shorter women require less anesthesia than a taller woman? 

ﾠThe dose of an anesthetic agent is partly determined by weight. Taller women are likely to be heavier than shorter women. The same would apply to men! In the case of epidural anesthesia, the relation between dose and height is not quite as important as between dose and weight, but a short person will on average also require less. The volume of the epidural space, where the drugs are injected, is smaller. 

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. 

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. 

I had an IV placed in my arm approximately 2 months ago, and am experiencing a large lump still to this day. Its now red and very sore around the area and seems to be getting bigger. Is this a cause for concern?? 

It isﾠ not possible to say what your problem is without a full history and a physical examination, so you should be sure to see your doctor as soon as possible.You may have thrombophlebitis - inflammation of the vein - with, or without, a blood clot in the vein (thrombosis). If the areaﾠis extremely tender and warm you may have developed an abscess, which would require treatment right away with antibiotics. 

How common is vocal cord paralysis post op? 

Minor trauma to the vocal cords, resulting in temporary hoarseness, is a relatively common complication of endotracheal intubation. Vocal cord paralysis is fortunately rare (much less than 1%). All complications of intubation are more likely to occur with prolonged intubation as in the case of critically ill patients in intensive care units. The left vocal cord is more often involved than the right, although cases affecting both sides can occur. Patients usually complain of hoarseness, but may develop airway obstruction which is obviously far more serious. Apart from duration of intubation, other factors may increase the risk, such as use of a large endotracheal tube, excessive pressure in the inflatable cuff used to seal the airway, or placement of the tube cuff close the vocal cords. The cause of vocal cord paralysis is thought to be compression of the recurrent laryngeal nerve by the endotracheal tube cuff as it enters the larynx between the cricoid and arytenoid cartilages . ENT doctors can diagnose the problem with a special test called electromyography and with direct laryngoscopy (visual examination of the vocal cords). In most cases, the vocal cords will recover, on average taking about 3 months. 

How do you know how much medicine to put into a shot to give to a patient? 

ﾠThat is a very big question! Drug dosing depends on the effects of the drug on the body (the science of pharmacodynamics), and the effects of the body on the drug (pharmacokinetics). It`s what medical professionals go to school for a long time to learn. As far as anesthetic medications are concerned, keep in mind that these drugs are all "poisons" which can suppress vital functions of the body such as breathing and heart function. Don`t try this at home!! 

When I get local or general anesthesia, I get an icy cold feeling in my chest for several minutes like I downed a glass of ice water. I am 40 years old and have borderline HBP which I take a low dose of medication. Is this an allergy to anesthesia? 

I am afraid I've never encountered the reaction you describe so I cannot offer an explanation. It certainly doesn't sound like an allergic reaction. 

I had surgery about 2 1/2 years ago and had an IV in topside of my right hand. My surgery was early morning and I woke up during the night after the surgery with my hand and arm hurting - I called the nurse and my hand and arm up to my elbow looked like they were going to explode they were so swolen. They immediately removed the IV. Afterward the veins in my hand were so large and hard for weeks then where the IV had been the veins began to shink to almost nothing. When looking at my arm (palm up) the veins look lumpy particularly if I place my hand lightly on my arm. I mentioned to my regulard doctor and he said it was scaring of the veins and nothing to worry about. Ever since the surgery, my hand gets so cold and my hand and forearm hurt almost as if the circulation is poor and it is more uncomfortable in the cold weather months - sometimes at work I turn on a portable heater and place my hand close to it (I work inside in computer department). Any thoughts on this, I have concerns if there could be serious damage to the veins in my hand and arm. 

It sounds as though your IV "infiltrated" or became "interstitial". In other words, the intravenous catheter became misplaced, and the intravenous fluids entered the tissues of your hand arm. This is a recognised complication of intravenous infusions. Most times there is no permanent injury. The fluid gets absorbed into your system, and the swelling goes down. The lumpiness of the veins suggests you had in addition some degree of phlebitis or thrombophlebitis. Please see the article referenced below for more information. Your current, persistent, problems are a bit more worrying. You may have developed what used to be called reflex sympathetic dystrophy, now named Complex Regional Pain Syndrome, a strange set of symptoms that can occur after various kinds of injuries to an extremity. It is characterized by pain, swelling, color change and occasionally sweating, tremor or decreased strength and range of motion of the extremity. Often, the psyche of the patient is affected. The RSD Association website and related sites may offer useful information. However, you should see an experienced Pain Medicine specialist and possibly other specialists for accurate diagnosis and treatment of the condition. Should the diagnosis of RSD (CRPS) be confirmed, occupational therapy and rehab of the upper extremity will be the mainstay of therapy with occasional interventions by the pain doctor as needed. 

I was hospitalized lastﾠSaturday for a severe migraine. They hooked me up to IV for about 3 hours to administer pain meds and anti nausea meds, along with the fluids. They removed it after giving me some narcotic for the pain and I went home. On Tuesday AM I woke up with a sore wrist and forearm and some swelling, no redness. It`s now Thursday and it still is swollen, a little less but still sore. What`s the story? 

ﾠYou don't say where the IV was sited and whether it corresponds with the area that is now sore and swollen. Assuming it is the same area, you might have some mild phlebitis (inflammation of the vein) or some of the fluid administered via the IV might have leaked into the surrounding tissues. Another possibility is that the pain and swelling are completely unrelated to the IV or the medication you were given. Perhaps you have some arthritis or some sort of muscle or tendon problem. Please consult with your doctor to make a proper diagnosis, especially if your symptoms worsen or fail to improve. 

From time to time, when reading articles, in both journals and popular publications, I see mention of amnesia resulting from certain medications given with anesthesia, either general or regional. I get the impression that this amnesia is a desirable side effect, rather than an unfortunate effect incidental to the medication`s primary function or purpose. Is amnesia after surgery truly a sought-after result? If so, please explain the rationale. 

Great question! Amnesia is generally regarded as one of the goals of general anesthesia. Anesthetic drugs impair the acquisition and encoding of new information while leaving the retrieval of previously learned material intact. The degree and duration of memory impairment progressively increase as the dose of each drug is increased. Since surgery is really a permitted assault on the body, most individuals prefer to avoid awareness of the attack as it takes place! The sounds and sensations of oneﾒs flesh and bone being drilled, sawn, cauterized, sliced and stapled are usually regarded as unpleasant, although not universally so. It is possible to accomplish painless surgery, yet retain consciousness, awareness and recall of events by using regional anesthesia. Regional anesthetic techniques include spinal and epidural anesthesia. A few of our hardier patients do request regional anesthesia, without sedative drugs, in order to prevent amnesia and retain full control of their senses. One situation in which amnesia is generally regarded as undesirable is that of childbirth by cesarean section. In our setting we try very hard to avoid administering sedatives to women, who are usually operated on under epidural anesthesia, at least until the baby has been delivered and presented to the mother. This helps to preserve the motherﾒs memory of that precious moment. 

Is it possible to get anesthesia somehow without an IV? Can I get it in a gas form? I am terrified of needles....and I am not looking forward to getting an IV. Please help. 

You can get put to sleep without an IV. This is called an inhalational induction. You breathe a mixture of anesthetic gas - sevoflurane is the best agent available today - and oxygen, sometimes with nitrous oxide. Over a period of 1 to 5 minutes general anesthesia can be achieved. This is the method used in small children, but is rarely done with adults. The gas is not all that pleasant to breathe so after trying it you might actually decide that an IV is not the worst thing in the world. Small children can't readily be made to cooperate for a needle, but as an adult you should be able to master it, especially if you're given some oral premedication 45 minutes to an hour beforehand. The premed will get you relaxed. Another trick used with children is to apply a mix of local anesthetics to the skin site of the needle insertion which over an hour or so numbs it up so that the needle is hardly felt at all. Finally, you can get general anesthesia from an intramuscular injection of a drug like ketamine, or midazolam. So, no IV, but still a needle. With any of these non-IV methods of inducing anesthesia, the IV can be inserted once you're unconscious. Presumably you're not going to mind at that stage. 

I was given anesthesia for a surgery and after I have been very itchy. Why is that? And will it stop? 

There are many causes for itchiness that include many different diseases of the skin as well as diseases originating in other parts of the body, such as allergy, infections, infestations, organ failure, and even cancer. There are also environmental causes such as excessive washing that depletes skin oils, compounded by the dehydrating effect of dry, climate-controlled air. A common reason for itching (pruritus) after surgery is the administration of opioids - that is pain killers like morphine or meperidine, especially if given via epidural or spinal anesthesia. The itchiness lasts roughly as long as the effect of the pain killer and probably is a "central" effect through the action of the drug on opioid receptors in the brain. 

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 had a hip replacement one month ago. I seem to have lost my sense of taste since this surgery. It is slowly coming back but not yet back to my baseline. Is this possibly due to the anesthesia? If so, can you explain the pathophysiology. Thanks in advance. 

Although this is not the first time I've been asked this question I'm still not aware of any links between anesthesia and the loss of the sense of taste after surgery. I suspect this is a random coincidence and I cannot explain, even in theory, how it might occur. Hip replacement surgery is usually done with regional (epidural or spinal) anesthesia, not general anesthesia, which would make it even harder to explain any connection. 

I have surgery in a few weeks and recently have been having low blood sugar in the morning (or during the night). One test said I may have nocturnal hypoglycemia. If my surgery is at 9am, and I haven't eaten, how do I overcome those low sugar feelings if I can't eat..and more importantly..what happens during the two hour procedure if its low or drops further? 

Are you diabetic? Low blood sugar typically, or hypoglycemia, occurs in people with diabetes who take sugar-lowering medication. If so, you should consult your personal physician about how to better manage your medication and diet. If you're not diabetic, low blood sugar is rather rare. You don't state what the sugar level was - it can easily be measured with devices for home use. Try not to confuse the "low sugar feelings" with actual low measured sugar (glucose) levels. Prolonged and very low levels can lead to such serious consequences as coma and brain damage. But low sugar feelings, at least in conventional medical thinking, probably represent hunger, fatigue or something else equally benign. If you are really worried about your sugar becoming low around the time of your surgery, when you are not permitted to eat, I would suggest you mention this to the doctors taking care of you. Most institutions will allow the consumption of clear fluids, which can contain sugar, up to 2-3 hours before anesthesia (check with the hospital, the surgeon, or the anesthesiologist). Your sugar (glucose) can be measured immediately before you go in for your operation, and can also be measured while you are under anesthesia. If the levels are low, you can be given sugar-containing solutions intravenously to raise and maintain your sugar at normal levels. 

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. 

After knee replacement surgery, I was placed on a PCA morphine pump. While using the PCA, I stopped breathing and had to be coded, fortunately with no lasting ill effect. I has been on a morphine PCA for a prior surgery a year before with no problem. I am 71 with controlled hypertension and diabetes 2 but otherwise in good health. How could this have happened? I thought the PCA was calibrated and only allowed a safe dose with lock out periods so that the patient didn`t get too much morphine. The doctor said I overdosed. If I ever need surgery again, should I say that I am allergic to morphine? Is the PCA dangerous? I am ready to have my other knee replaced and I am nervous about it. 

Those are very good questions. In order to avoid a similar outcome the next time you need a surgical procedure it's extremely important that you have a good understanding of what happened. You are fortunate that you were rescued and have suffered no ill effect. The first thing to do would be to get accurate, written records of your previous hospitalization, including the misadventure with Patient Controlled Analgesia (PCA). Perhaps your doctor could arrange for a brief summary of events, in the form of a letter, to be written by the appropriate physician - for example the doctor in charge of the intensive care unit where presumably you were cared for. Without such a record it is impossible to say exactly what happened and how a future event should be prevented. If you are having your surgery in the same hospital, the doctors should have ready access to the records, but you should make sure the records are retrieved and reviewed before your surgery. It is very unlikely that you are "allergic" to morphine. Allergy to morphine does occur but is quite rare. The more likely explanation, as you have said, is that you received too much, or at least too much for YOU. Morphine, and all the other strong, "opioid" pain relievers have the unfortunate side-effect of decreasing your breathing. However, the dose of morphine that one person needs for pain relief can be enough to stop another person from breathing. There is a large amount of individual variation in the "tolerance" for morphine, even in persons of the same age and weight. When delivered by PCA machine drugs like morphine are quite safe, because sedation usually precedes severe respiratory depression. When you become sedated you are unlikely to press the button to give yourself more morphine, so the system has built-in safety. The sedation, and the pain relief, must wear off before you are awake enough to press the button again. But, like everything else in medicine there are no absolute guarantees of safety, or effectiveness. The PCA machine can be programmed incorrectly. Someone else might have pressed the button. The wrong concentration of drug might have been put in the machine. The machine might have been programmed to give you a continuous infusion of morphine - this bypasses a safety element but is nevertheless one of the conventional methods of administering PCA. So, there are many possibilities, and it's not possible for me to say what happened to you. A potentially fatal adverse event of this nature demands a full explanation and I'm sure you'll get it from your doctors and your hospital. With this information your doctors can devise a treatment plan that should make it be possible for you to have a safe and comfortable postoperative recovery from your next surgery, with or without PCA analgesia. 

Iﾠhad an IV placed in the top of my hand for approx. 3 hours. a bruise appeared the next day, but no pain/swelling. Now, 5 days later my wrist (below the site) and forearm are VERY sore and swollen, like I can follow the vein up my arm, my wrist is very stiff and swollen. Should I be concerned??? 

It sounds as though you have developed phlebitis, or thrombophlebitis. This is a condition of inflammation of veins that may also be associated with blood clot formation in the vein. Phlebitis is fairly common after IV placement. You should be concerned if the condition is not improving, if you have a fever, if the glands in your axilla (armpit) are swollen,ﾠor if you feel generally unwell. Uncomplicated phlebitis normally heals on its own, and the treatment is "symptomatic" - that is, things which improve symptoms, like simple pain relievers and local heat. In some cases however the phlebitis can become septic - infected. This can be a very serious problem needing urgent treatment with antibiotics. You should seek attention as soon as possible from your healthcare provider to make sure you are not developing this more serious condition. 

During a recent trip to the ER I had an IV inserted into my hand. What would have caused body twisting pain when the RN injected meds in the IV? This happened also when the CT tech injected me prior to xray. I have had IV`s before and never had this problem. 

ﾠThat is a bit unusual. Severe pain during an IV injection may have to do with the IV cannula, or with the medication that was injected. Certain medications can cause pain on injection. An example is the common anesthetic agent called propofol (Diprivan). This drug causes pain that may be quite severe though transient (just a few seconds). There are other drugs that have similar irritant properties..one that comes to mind is Valium (diazepam). The other possibility is that the cannula is somehow misplaced. The tip of the cannula may be wholly or partially in the tissues. If this is the case it is usually possible to detect the misplacement because the tissues will swell as more intravenous fluid is given. Hopefully you did not have any permanent adverse effects from the IV cannula. Please refer to another answer I have given recently on the issue of complications of IV cannulas. 

I had a hysterectomy 6 mo ago, it took the nurses 8 tries to hit a vein, which was crazy because I have easy veins to hit. They finally put the IV on the inside of my forearm at the bend. When I woke up from surgery the pain in my arm was worse then my surgery. I had a burning pain from my hand all the way up to my sholder, numbness in my hand, throbbing pain over my entire arm. The overall pain has lessened and eventually went away. Last month I went to have routine blood work and the pain is back all over again and almost made me pass out and I am not sensitive like that, it almost felt like there was a burr on the needle, arm still hurts. . Any answer of what is going on? 

In the course of medical treatment about 25 million Americans have intravenous catheters placed each year. Serious complications are very uncommon, but problems can occur. These problems include infection, thrombosis (blood clot in the blood vessel), phlebitis (inflammation of the blood vessel), hematoma (blood clot in the tissues next to the blood vessel, emboli (small blood clots dislodged from the inside of the blood vessel), and infiltration (the catheter goes into the tissues next to the blood vessel). It is also possible for the needle to penetrate and injure a nerve, and for bruising and bleeding to irritate a nerve. Nerves are invisible from the skin surface so you can understand how this might happen. There are a couple of larger nerves that supply the forearm and that pass through the area at the inside of the elbow. These are the median and radial nerves. It's possible in your case that one of those nerves was injured by the IV needle or catheter. In most cases, such an injury would heal over a few weeks or months. I believe that injuries from intravenous catheters and from blood draws ("phlebotomy") are under-appreciated. There is little information in the medical literature on this subject. However a 1996 study of 419,000 blood donations showed that 1 in every 6300 donors had a nerve injury. Fortunately, most got better within a month. The symptoms included excessive or radiating pain, and loss of arm or hand strength. Fifty-two of 56 donors achieved a full recovery, and 4 other donors had only a mild, localized, residual numbness. The inside of the elbow is not usually the best place to insert an IV, except in an emergency or when other sites are not available. It is however the commonest site from which blood is withdrawn. I hope that having blood drawn from this site has not made your unpleasant symptoms come back again. If your symptoms persist you should consult a physician because in rare instances (such as persistent weakness) specific treatment, even surgery, may become necessary. I think that in the future you should avoid having blood taken, or an intravenous catheter (IV) inserted, in that part of your arm. 

I had surgery 4 weeks ago and had an IV in my right wrist for 4 days. My wrist is is more sore now then when I had the IV and there appears to be a "knot" where the IV was placed. What can I do to make the pain and "knot" go away? 

This problem - pain after intravenous ("IV") catheter insertion - is one I've commented on previously. What I've said is that a small number of people who undergo the very common procedure of IV insertion, or have blood drawn, end up with injuries, usually minor. In your case, the "knot" might be a small hematoma (blood clot) in a blood vessel that is inflamed. This is known as phlebitis, or thrombophlebitis. It gets better with basic pain relief measures - pain medicine, anti-inflammatory medication, local heat. Occasionally, a nerve can be injured - here the pain is more persistent and is not just in the area where the IV was sited. If this is the case, you should seek attention from your doctor. It all goes to show that even minor medical procedures - like IVs or blood draws are, unfortunately, not completely without risk. 

I had shoulder surgery two weeks ago. To control the pain, they gave me two shots in my thigh at 4 hour intervals. The shots were a combination of Demerol (75mg) and Vistaril (50mg). For the past two weeks, in the area where they gave me the shots I have had, "Sensory neuropathies commonly associated with parasthesias numbness, tingling, or hypersensitivity to touch". Is there anything that can be done about this? 

An intramuscular injection ("shots") can very rarely cause injury to an underlying nerve. A nerve that is injured by a needle can cause numbness, parasthesiae (tingling, "pins and needles" sensations) or pain. Another possibility is that you may have a problem completely unrelated to the injections, such as a herniated disc in the lumbar spine. I would advise you to contact your doctor so that your complaints can be fully evaluated. 

The past two times that I`ve had anesthesia administered, I`ve gotten severe nausea and vomiting for several hours after the surgery. Is it that I`m sensitive to anesthesia and should I let my physician know about this? 

You may be one of those individuals - usually younger, female, non-smokers, with much more risk of post-operative nausea and vomiting. You should definitely let your physicians know about thisﾠ most unpleasant problem. It may not be possible to eliminate it entirely but there are techniques for reducing the risk quite a bit. 

My son in law had knee surgery a week ago and now has large blistering on his throat, very sore, sick to stomach, fever, aching - what do we do? 

I'm not sure whether those symptoms have anything to do with your son-in-law's anesthetic a week ago but you haven't given me any information that suggests that it does. A sore throat after general anesthesia is quite common but blistering is definitely not. There are many possible causes of the symptoms you have described including severe allergic reactions, infections and blood problems. You should advise your son-in-law to consult a physician as soon as possible. 

I`m having a tummy tuck in a week and I was wondering how and if smoking will affect the anesthesia. 

ﾠSmoking increases your risk of respiratory complications and your risk of wound infection. Your upcoming surgery represents a perfect opportunity to quit. Ideally you would stop 6 or more weeks before surgery to get maximum benefit, but the consensus is that any time before surgery is a good time to stop. Even if you stop for only 24 hours before the procedure this will increase the oxygen-carrying capacity of the blood. Smoking cessation programs are widely available in many places and your hospital or surgery center may be able to direct you to such programs. Smoking cessation aids like nicotine patches, gum, and drugs like buproprion can help you through it. 

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. 

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. 

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! 

I`m really nervous about an upcoming tummy tuck that I`m having. I`m a recent smoker but have decided to quit and am now using the patch. Are the risks during surgery the same as if you were still smoking? Should I remove the patch before surgery? My surgery is in 3 days, I`ve only been wearing the patch for 2 days, is even stopping at this late of date going to help? Should I inform the the anesthesiologist of what I`m doing? Would it change the way they treat me? 

Withholding information from your anesthesiologist about medication you're taking is a very bad idea. I'm sure you don't need to be told why! The most benefit is if you stop smoking for 6 weeks or more but stopping smoking for only 5 days is still worth it. Some people who have recently stopped have a temporary increase in secretions in the lung, a potential drawback. But other effects are positive, including eliminating carbon monoxide, carried on the hemoglobin of smokers, from your blood. Not to mention the potential long term benefits of having quit - reduced heart and lung disease, cancer, etc. I assume you mean the nicotine patch. Having the patch in place is not likely to change your anesthetic in any way. The patch provides a slow release of nicotine to combat withdrawal symptoms and the subsequent urge to smoke. There are no important interactions I know of between the nicotine patch and anesthetic medications. 

I am having surgery tomorrow to open a closed tear duct which could not be opened by probing in the office. One nurse told me not to eat or drink anything 8 hours prior to surgery (which is at 2:30 p.m.) and another said have a piece of toast and cup of black coffee. Which is correct? Also - they called yesterday and said do not take any ibuprofen 2 weeks prior to the surgery - and I take it regularly for shoulder pain - having taken it as recently as 2 days ago. Having told the nurse this, she said not to worry about it. Again, which is it and should I call and speak directly with someone in charge? Suddenly, I feel like they are just trying to push through the surgery. 

The Guidelines of the American Society of Anesthesiologists (http://www.asahq.org/patientEducation/SedationBrochure.pdf) apply to healthy patients undergoing elective surgery.ﾠThe guidelines state: Patients may be allowed to drink CLEAR fluids until 2 - 3 hours before anesthesia. Black coffee would be considered a clear fluid. Patients may have a light meal up to 6 hours before the surgery. Toast would be considered a light meal. Anti-inflammatory drugs like ibuprofen affect the function of platelets, the cells in your blood that enable clotting to occur. If you are to undergo a surgical procedure with a high risk of bleeding, then it is advisable to stop using ibuprofen. It takes 3 - 5 days for the effects of ibuprofen on platelets to disappear. Unblocking a tear duct would be not be considered a procedure with a high risk for bleeding. Guidelines such as those from the ASA are just that, guidelines. Each doctor and each institution must interpret the scientific evidence in the light of local needs, their patient population, and their surgical practice. So if you are unclear about what you are supposed to do you should definitely call whoever is in charge to clarify. 

I am wondering why a person with no previous drug abuse is almost impossible to put under for a procedure? This person is 6 ft and 250lbs but has had no success using pain killers like morphine when hospitalized. Most recently he was not able to be put under for a colonoscopy. They think it is a history of drug use but it is not. Will you tell me what the other posiblilties it could be for future of this persons care. 

Thanks for your question. There are very interesting variations in how people respond to anesthetic and sedative drugs. Recently I had a patient to whom we gave roughly ten times the usual "premed" sedative IV dose of midazolam (Versed) without any apparent effect on her. This patient was a rather petite middle-aged woman without a history of drug use or abuse. We often see large variations in how people respond to opioid pain-killer medicine (morphine is an example) also. A person who is of large build, as you describe, would be expected to need more sedative and pain-killer medicine than a person of average build. You describe the experience as "no success using pain-killers". However, almost always, there is a dose-response curve. In other words, more drug, more effect. The problem is that prescriptions for opioids like morphine are usually written with a maximum stated dose, because of concerns for the side-effects of morphine, which include the suppression of breathing. Nurses cannot administer more than the prescribed dose. Even with patient controlled analgesia (PCA) the machine has preset limits, again for safety reasons. In these circumstances, somebody has to over-ride the prescribed or preset limits, while supervising the administration to make sure that unpleasant or dangerous side-effects do not occur. There are also genetic variations in the metabolism of and response to PARTICULAR drugs including opioids. Sometimes switching opioids - e.g. trying hydromorphone instead of morphine, will produce results. Other times, additional pain-killer medications from a different class - e.g. ketamine - can be added with good effect. The lack of success with colonoscopy suggests that similar drugs to the ones I've described above were used. Anyone with really high requirements for these medications will not have a great experience in the common setting of colonoscopy with nurse-administered sedation. In this setting, there will again be reluctance to administer the very high doses that might be necessary. The drug called propofol, which is both a sedative and anesthetic agent can be given by a properly credentialed anesthesia provider to achieve the deep sedative state needed for this outpatient procedure, and still produce safe, calm operating conditions, a relatively pleasant experience for the patients, and quick recovery for home-going. 

I had outpatient surgery 10 days ago and every time I move my wrist I get a twinge of pain due to the IV needle insertion. I won't mention the horrible bruising that lasts for weeks from failed needle insertions from past surgeries. I`ve been told my veins aren`t difficult but it seems OR personnel are careless. This has happened to others I`ve spoken with, and it truly is more common than not. The charge anesthesiologist always leaves this `unimportant` (in his mind) task to the CRNA`s who frankly are harsh and uncaring. Please comment. 

I know you are being ironic and of course inserting an IV cannula is not a trivial orﾠunimportant task - if you are the person it's being inserted into! You might in future politely request that the most experienced availableﾠpractitioner insert your IV. Hopefully you would then be less likely to end upﾠwith a painful or bruised arm. During an unsuccessful (or successful) IV insertion the vein is penetrated. When the needle or cannula is withdrawn the vessel will bleed. Prolonged compression at the site is needed to avoid blood leaking out of the injured vessel and into the tissues - a bruise. IV insertion occasionally results in minor nerve injury. Unfortunately we don't have a routine method of visualizing small structures like tiny sensory nerves that might get in the way of the needle.ﾠ