Anesthesia & You

Anesthesia - General, Regional or Local?

General anesthesia
General anesthesia may seem like being asleep but it's quite different. During general anesthesia, your anesthesiologist keeps you in a state of carefully controlled unconsciousness, with a mixture of very potent drugs, so that the operation is painless. Many people think that this involves the injection of just one drug. Actually, most general anesthetics require the administration of somewhere between three and fifteen different drugs, depending on the complexity of the case.

A typical general anesthetic given for gallbladder removal might involve the intravenous injection of pentothal to make the patient unconscious, followed by a mixture of narcotics and anesthetic gases to keep the patient unconscious. A muscle relaxant is given to relax muscles of the to help the surgeon. Oxygen is administered constantly, initially with a mask over the face, and then through a breathing tube inserted through the mouth into the windpipe, after the patient is unconscious. A mechanical breathing machine, called a ventilator, is attached. All the patient's bodily functions are carefully controlled and monitored. At the end of the operation, the effect of the muscle relaxants is reversed with two other drugs, and the anesthetic gases discontinued. When the patient is conscious and able to breathe without help, the ventilator is stopped and the breathing tube removed. All intravenous drugs and anesthetic gases are administered in appropriate amounts so that the patient is completely unconscious during the surgery, but awake and pain free at the end.

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Regional anesthesia
Regional anesthesia involves injecting local anesthetics through a needle, which the anesthesiologist places close to the nerve or nerves supplying the region of the body involved in the operation. The skin and tissues that the needle goes through are also numbed with local anesthetic so that there is minimal discomfort associated with placement of the needle. Local anesthetic drugs stop nerves from working temporarily, so that no sensation and/or movement in the area of the body supplied by the nerve(s) occurs. This type of anesthesia is also called a nerve block.

The most common type of regional anesthesia is spinal anesthesia. This can be used to anesthetize the abdomen and legs. Many other 'regions' of the body, such as an arm, can be safely and comfortably anesthetized. The effect of different local anesthetics lasts for different times, so the length of the anesthetic can be tailored to your operation. You may remain completely awake if you wish, but usually your anesthesiologist will administer a drug to make you relaxed and drowsy. At the end of the operation patients are transferred to the post anesthetic care unit awake, relaxed and pain free. They are usually very pleased with this type of anesthetic.

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Local anesthesia
Local anesthesia refers to temporarily numbing a small area by injecting local anesthetic into the skin so that minor procedures like stitching cuts can be done painlessly.

The Post Anesthesia Care Unit (PACU)
This is where you go at the end of the operation to recover from the immediate effects of anesthesia and surgery. Nurses with special expertise will look after you. The anesthesiologist will supervise your medical care until you are stable enough to transfer out of this unit, either to go home after day surgery or to the ward if you are an inpatient. Your surgeon will also follow your progress in the PACU, and will be called to see you have any surgical problems.

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Anesthesiologists and critical care
Critical care is the special intensive care that you need when you are critically ill as a result of a serious injury, complicated major surgery, or a very serious medical illness. It is provided by specially trained physicians and nurses in critical care areas, called intensive care units.

Historically, anesthesiologists developed the technique of artificially breathing for patients by placing a tube directly into the windpipe and connecting it to a mechanical breathing machine. Critically ill patients often develop lung problems and used to die from acute respiratory failure. Mechanical ventilation allowed us to keep these people alive while they recovered from their other problems, and was the beginning of intensive care, as we know it today. Anesthesiologists remain the experts in the placement of these breathing tubes and in all types of resuscitation, and teach these skills to other physicians.

It is usually an anesthesiologists that looks after critically ill patients in the PACU and ICU following major surgery. They are also frequently involved in the care of other patients in the ICU, particularly those who need mechanical ventilation for any reason. In the main ICU of large referral hospitals, where the most complicated, critically ill patients are treated, physicians who specialize in intensive care look after the patients. In the past, most of these physicians were anesthesiologists, however intensive care has now become a multidisciplinary specialty, and these physicians may be surgeons, internists, or anesthesiologists. About thirty percent of intensivists in Canada are anesthesiologists, but in some countries such as the United Kingdom and Australia, the percentage is much higher.

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The maternity unit
Anesthesiologists are involved around the clock in the care of pregnant women on delivery units. The physicians supervising the delivery frequently consult anesthesiologists to provide pain relief in labor, anesthesia for cesarean sections, and neonatal resuscitation.

Epidural analgesia requires the insertion of a small plastic tube or catheter into the back. Small amounts of local anesthetic are injected through the tube near the nerves that supply the parts of the body involved in childbirth. It is very safe and reliable, when done by an experienced anesthesiologist, in appropriate circumstances.

The procedure was developed by anesthesiologists to relieve the severe pain that many women experience with childbirth. It is superbly successful at doing that for those who wish it. About thirty five percent of women in labor in Canada have an epidural inserted by an anesthesiologist for relief of pain when they deliver their babies.

About nineteen percent of deliveries in this country are performed by cesarean section. Many of them are emergencies because of concerns about the wellbeing of the mother or baby. Needless to say, an anesthetic is needed before having a cesarean section. When emergency cesarean section is needed to save the life of the unborn baby, the anesthesiologist must insure the safety and comfort of both the mother and the baby, while the obstetrician delivers the baby as soon as possible. This is some of the most stressful, yet rewarding, work that anesthesiologists do.

Sometimes when babies are just born they do not breathe as well as they should, and need help to get them through this, usually, brief period. Occasionally there are more serious problems and the baby will need a breathing tube inserted temporarily. Rarely a baby will need to be mechanically ventilated and transported to a neonatal intensive care unit in another hospital. Anesthesiologists often provide this care, along with other physicians who have special training in this area.

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Acute pain management This is the treatment of pain that occurs temporarily after surgery or some other type of trauma. Anesthesiologists have developed its treatment to the point where it is possible to avoid severe pain in most circumstances, particularly after surgery.

The use of epidural analgesia, first developed for labor pain, has now been extended to a wide range of surgical procedures, such as major leg, abdominal and chest surgery. An 'epidural' allows patients to remain comfortable after these types of operations. A small amount of medication is continuously infused through the epidural catheter and numbs the painful area. Only several years ago, patients undergoing these operations would have been in extreme pain for several days after surgery. They would have required large amounts of narcotic drugs, such as morphine. These drugs made the patients sleepy, disorientated, and often extremely nauseated. It is impressive to see them now - alert, orientated, comfortable, and nausea free. They are able to get up sooner and this speeds recovery and reduces complications. Epidural analgesia is a major advance of modern medicine.

For patients whose pain control does not require epidural analgesia, a range of treatment is available. These treatments use combinations of non-narcotic drugs and/or nerve blocks to minimize the amount of narcotic medication needed to keep patients comfortable. Special pumps allow patients to control the amount of narcotic medication they get, according to how much pain they have.

Some patients require very special acute pain control. For example, large amounts of narcotics and other medications are often needed by people with terminal cancer to cope with their chronic pain. They may require extremely large doses of medication after surgery to adequately deal with their new postoperative pain. Nerve blocks may also be very helpful. Until recently, these patients often suffered a great deal after surgery. Anesthesiologists are now usually involved in their care, because of their expertise in acute pain management, and are able to derive great professional satisfaction from helping them.

Sophisticated acute pain management requires the expertise of anesthesiologists, and they supervise the complicated pain management of patients all over the hospital.

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Chronic pain management
This is the treatment of chronic pain, that never goes away. There are many causes. Some are well known like the debilitating pain that some people with terminal cancer experience. Other are less obvious, such as the phantom limb pain suffered by some amputees.

Some anesthesiologists specialize in the treatment of these difficult and often agonizing conditions. They are consulted by other physicians for their help in treating these patients in the hospital, or in chronic pain clinics. Because this type of practice is extremely time consuming and requires significant extra training, anesthesiologists specializing in chronic pain management are in short supply and are much sought after.

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