This column is directed to my non-medical layperson readers. As an experienced board-certified physician anesthesiologist, I will attempt to answer frequently asked questions FAQ about anesthesia.
- WILL I BE NAUSEATED OR VOMIT AFTER GENERAL ANESTHESIA?
One of the most common fears patients have before surgery is, “Will the anesthesia make me nauseated?
The answer is, “Possibly.” The anesthesia medical literature contains thousands of published papers studying the science behind post-operative nausea and vomiting (PONV), and the best strategies to prevent it.
The four traits that have been found to best correlate with PONV are:
- female gender,
- a patient that does not smoke tobacco,
- a patient with a past history of PONV or motion sickness, and
- the use of postoperative intravenous narcotic pain relievers.
When 0, 1, 2, 3, or 4 of these factors are present, the risk for PONV is about 10%, 20%, 40%, 60%, or 80%, respectively.
- HOW SAFE IS ANESTHESIA IN THE 21ST CENTURY?
Deep down, every surgical patient has the same worry: How safe is surgery and anesthesia?
Methods of evaluating anesthetic mortality are inexact and controversial. In 1999 the Institute of Medicine published their report entitled To Err is Human: Building a Safer Health Care System. In this report, the Committee on Quality of Health Care in America stated that, “anesthesia is an area in which very impressive improvements in safety have been made.” The Committee cited anesthesia mortality rates that decreased from 1 death per 5,000 anesthetics administered during the 1980s, to 1 death per 200,000-300,000 anesthetics administered in 1999. These statistics reflected the frequency of all patients, healthy or ill, who died in the operating room.
- HOW MUCH TRAINING DOES MY ANESTHESIOLOGIST HAVE?
Anesthesiologists are Medical Doctors. In the United States, anesthesiologists are required to have the following minimum training following high school:
1. College degree = 4 years
2. Medical school degree (M.D. or D.O.) = 4 years
3. Internship = 1 year
4 Residency in Anesthesiology = 3 years
This minimum timeline adds up to 12 years after high school. Most anesthesiologists are 30 years old or older before they are finished training.
- HOW MUCH TRAINING DOES A NURSE ANESTHETIST HAVE?
Nurse anesthetists, or CRNA’s, have the following training:
- A Bachelor’s Degree in a science-related field. They must be licensed as a Registered Nurse (R.N.)
- They must have 2 years minimum experience as an acute care nurse, e.g. in an Intensive Care (ICU) setting.
- They must complete a 24 – 36 month training program in anesthesia.
- WILL I HAVE AN ANESTHESIOLOGIST OR A NURSE ANESTHETIST FOR MY ANESTHESIA PRACTITIONER?
In the U.S., solo M.D. practitioners deliver 35% of the anesthetics, anesthesia care teams with anesthesiologists medically directing Anesthesiologist Assistants or CRNAs deliver 55% of the anesthetics, and CRNAs in solo practice deliver 10% of the anesthetics. The anesthesia care team model is less common in California, partly because the supply of anesthesiologists in California is sufficient to staff most cases without CRNAs.
- WHAT DOES IT MEAN TO HAVE GENERAL ANESTHESIA?
A general anesthetic renders the patient asleep and insensitive to pain for surgery. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. Before the anesthetic, oxygen is administered by mask to fill the patient’s lungs with 100% oxygen. Most adult patients are given general anesthesia by intravenous injection, usually of the medication propofol. This injection causes the patient to lose consciousness within 10 – 20 seconds. This is called the induction of anesthesia. The maintenance of anesthesia during surgery is done by mixing an anesthesia gas or gases with the oxygen. Typical inhaled anesthesia gases are nitrous oxide, sevoflurane, or isoflurane. Sometimes a continuous infusion of intravenous anesthetic such as propofol is given as well. The choice and dose of drugs is done by the anesthesia attending, based on the patient’s size, age, the type of surgery, and the anesthesiologist’s experience.
- WHAT IS SPINAL ANESTHESIA?
Spinal anesthesia is done by the injection of local anesthetic solution into the low back into the subarachnoid space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word subarachnoid translates to “below the arachnoid”. The arachnoid is one of the layers of the meninges covering the nerves of the spinal column. In the subarachnoid space lies the cerebral spinal fluid (CSF) which surrounds the spinal cord and brain. In a spinal anesthetic, the subarachnoid space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected.
Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the subarachnoid space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.
Following the onset of numbness from spinal anesthesia, the patient may either stay awake for surgery, or more often intravenous anesthesia is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement spinal anesthesia.
- WHAT IS EPIDURAL ANESTHESIA?
Epidural anesthesia is done by the injection of local anesthetic solution, with or without a narcotic medication, into the low back into the epidural space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood. The word epidural translates to “outside the dura”. The dura is the outermost lining of the meninges covering the nerves of the spinal column. The epidural space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected. Often, a tiny catheter is left in the epidural space, taped to the patient’s low back, to allow repeated doses of the medication to be given. The catheter is removed at the end of surgery, or sometimes days later if continued epidural medications are administered for postoperative pain control.
Local anesthetics, such as lidocaine or bupivicaine (brand name Marcaine), given into the epidural space, bring on sensory and motor numbness. The anesthesiologist chooses the dose and type of drug depending on the patient’s age, size, height, medical condition, and the type of surgery.
Following the onset of numbness from epidural anesthesia, the patient may either stay awake for surgery, or more often intravenous sedation is given to achieve a light sleep. Sometimes light general anesthesia is given to supplement epidural anesthesia.
- WHAT IS REGIONAL ANESTHESIA?
Regional anesthesia is the injection of local anesthetic (either lidocaine or Marcaine) near a nerve to block that nerve’s function. Examples of regional anesthesia include arm blocks (axillary block, interscalene block, subclavicular block), and leg blocks (femoral block, sciatic block, popliteal block, ankle block). An advantage of regional anesthesia blocks is that the patient may remain awake for the surgery. If desired, the anesthesia provider may administer intravenous sedation or general anesthesia in addition to the regional anesthetic, to allow the patient to sleep during the surgery–the advantage of this combined anesthetic technique is the regional anesthetic blocks all surgical pain and less sleep drugs are required.
- WHAT KIND OF ANESTHESIA IS USED FOR CHILDBIRTH (OBSTETRICAL ANESTHESIA)?
Most obstetric anesthesia is for either vaginal delivery or for Cesarean sections.
Anesthesia for Vaginal Delivery: Anesthesia for vaginal delivery is utilized to diminish the pain of labor contractions, while leaving the mother as alert as possible, with as muscle strength as possible, to be able to push the baby out at the time of delivery. Anesthesia for labor and vaginal delivery is usually accomplished by epidural injection of the local anesthetics bupivicaine (brand name Marcaine) or ropivicaine.
is done by the injection of local anesthetic solution, with or without a narcotic medication, into the low back into the epidural space. Prior to beginning anesthesia, the anesthesiologist places monitors of blood pressure, electrocardiogram, pulse and oxygen saturation of the blood.
The word epidural translates to “outside the dura”. The dura is the outermost lining of the meninges covering the nerves of the spinal column. The epidural space is located with a needle by the anesthesiologist, and the appropriate anesthetic medications are injected. Often, a tiny catheter is left in the epidural space, taped to the patient’s low back, to allow repeated doses of the medication to be given. The catheter is removed after childbirth.
Anesthesia for Cesarean Section: Cesarean section is a surgical procedure in which the obstetrician makes an incision through the skin of the lower abdomen, and through the wall of the uterus, or womb, to extract the baby without the child requiring a vaginal delivery. Anesthesia for Cesarean section is usually a spinal or an epidural anesthetic, which leaves the mother as alert as possible, while rendering surgical anesthesia to her abdomen and pelvis. Spinal or epidural anesthesia is accomplished by injection of local anesthetics, with or without a narcotic medication, into the low back into the subarachnoid or the epidural space. The anesthesiologist remains present for the entire surgical procedure, to assure that the mother is comfortable and that all vital signs are maintained as close to normal limits as possible.
In a minority of cases, the anesthesia provider will administer a general anesthetic for Cesarean section surgery. The most common indications for general anesthesia are (1) emergency Cesarean, when there is no time for a spinal or epidural block; and (2) significant bleeding by the mother, leading to a low blood volume, which is an unsafe circumstance to administer a spinal or epidural block. General anesthetics for Cesarean section carry an increased risk over spinal/epidural anesthesia, primarily because the mother is no longer able to breath on her own and maintain her own airway.
- IS PROPOFOL SAFE?
Michael Jackson’s death begs the question: Is propofol a safe anesthetic?
Propofol is the most commonly used intravenous anesthetic drug in the United States today. In the hands of trained anesthetic professionals, propofol is very safe. Propofol in always injected directly into an intravenous line, and the onset of sedation occurs within seconds. The depth of sedation is dependent on the dose administered. Anesthesiologists commonly administer a dose sufficient to induce unconsciousness, which occurs within 15 seconds after the dose is injected from a syringe into a dripping intravenous line. The dose is based on the patient’s weight, the patient’s age, and the depth of sleep desired. In general, patients who weigh less, have advanced age, or have serious medical problems require less propofol.
Propofol is a hypnotic, or sleep-inducing drug. It is not a potent pain-reliever, and for painful surgical procedures, drugs such as narcotics or inhaled anesthetics are commonly administered in addition to propofol to blunt pain or deepen anesthesia.
The major hazard with propofol is that patients may stop breathing after a bolus dose, or they may obstruct their upper airway (think of severe snoring that transitions into total obstruction of air moving through the upper airway). Anesthesia professional are trained to manage these issues, and to keep adequate oxygen delivery and breathing to their patients.
Some non-anesthesiologists are trained to manage the cessation of breathing or the obstruction of breathing caused by anesthetics such as propofol. These non-anesthesiologists include certified registered nurse anesthetists; emergency room doctors; ear, nose, and throat (ENT) surgeons; and oral surgeons who administer anesthetics. The majority of physicians, including internal medicine doctors, family practitioners, cardiologists, pediatricians, other surgeons, obstetricians, gynecologists, gastroenterologists, and psychiatrists do not have the necessary training to safely administer propofol.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: