Posted on 07/27/2004 6:57:03 PM PDT by neverdem
At one time, any surgery under general anesthesia practically mandated a stay in the hospital, often to recover not from the surgery but from the effects of the anesthesia used during the operation.
Patients were woozy for hours, unable to get out of bed, nauseated and vomiting, and even if they wanted to eat, they couldn't because their digestive systems were paralyzed. People receiving anesthesia were also at risk; a significant number died not from their disease but from the anesthetic drugs themselves.
But new drugs and procedures developed in recent years have made anesthesia not only more comfortable, but much safer.
Despite two recent highly publicized deaths from anesthesia in a New York hospital, such events, shocking as they are, do not constitute a trend.
On the contrary, deaths from anesthesia in generally healthy patients have made a startling decline in the last two decades, decreasing to an estimated 1 in 250,000 cases from 1 in 10,000, according to the American Society of Anesthesiologists. And new drugs have become so easy to tolerate that many patients can undergo general anesthesia in the morning and be home, completely recovered, in time for dinner.
In fact, almost half of all surgeries are now done on an outpatient basis, either in a hospital, an ambulatory surgical facility, or a doctor's office.
Only general anesthesia knocks the patient out completely. Monitored anesthesia, sometimes called "conscious sedation," "sedation analgesia" or "twilight sleep," is widely used for breast biopsy, vasectomy, colonoscopy and endoscopy, among other procedures. The patient is conscious, but sleepy and relieved of pain.
Regional anesthesia involves the injection of an anesthetic near a nerve bundle to numb a specific region of the body. This is the kind of anesthesia that numbs the patient below the waist for childbirth, prostate surgery and leg or hip operations, and can also be used to numb other regions of the body.
Local anesthesia numbs only a part of the body, like the hand or the foot, leaving the patient completely awake.
In many surgeries, patients have a choice of anesthesias - local, regional or general. In picking one, suggests Dr. Karen B. Domino, professor of anesthesiology at the University of Washington School of Medicine, "Ask your anesthesiologist what he would choose if it were his child, parent or spouse having the surgery."
The increasing comfort and safety of general anesthesia are largely explained by vast improvements in operating room equipment over the past two decades, in particular the development and wide use of techniques called end-tidal capnography and pulse oximetry.
End-tidal capnography detects the level of carbon dioxide the patient is exhaling, which is essential in determining the correct position of the breathing tube. Intubation is a tricky procedure, and there is a danger of putting the tube into the esophagus rather than the trachea - a mistake that can cause brain damage and death from lack of oxygen. End-tidal capnography minimizes that risk.
Pulse oximetry gives the anesthesiologist a precise measure of the oxygen saturation of the patient's blood by sending light pulses through the skin at specific wave lengths that are absorbed in different amounts, depending on the oxygen content of the hemoglobin. A pulse oximetry clip is attached to the patient's finger or earlobe.
Another advance is the technique of tracing brain waves to chart the patient's state of wakefulness, though there is debate about its usefulness.
In a study published in the May 29 issue of The Lancet, Dr. Paul S. Myles, director of research in the department of anesthesia and pain management at Alfred Hospital in Melbourne, Australia, demonstrated the effectiveness of using an electroencephalograph, or EEG, to prevent one of the nastiest experiences in surgery: waking up during the procedure, feeling pain and being unable to move or communicate.
The technique, called bispectral index monitoring, or BIS monitoring, is used in only about a quarter of operations in the United States, and much less elsewhere. But Dr. Myles thinks it should be more widely used.
"My personal view," he said, "and this is open to debate, is that BIS monitoring should be used in all patients having a general anesthetic with a muscle relaxant, because a muscle relaxant removes the most reliable indicator of awareness: patient movement."
The additional cost of using the technique is about $20 per case.
Nausea and vomiting after anesthesia are not just uncomfortable, but dangerous because accidentally inhaling vomit can lead to pneumonia and life-threatening complications.
But new anti-nausea drugs, as well as anesthetics that themselves have anti-emetic properties, help anesthesiologists to minimize this problem prophylactically.
Dr. Myles said clinical trials had identified at least five types of anti-nausea drugs "that are quite effective and we often give a combination of these during surgery, before the patient wakes up."
Doing this, he added, "has reduced the risk of nausea and vomiting from about 40 percent to less than 10 percent."
When patients undergo general anesthesia, they usually first receive a drug called an induction agent that makes them drift off and lasts only a few minutes. A muscle relaxant may also be given. Then the anesthetics that keep patients asleep through the procedure are administered, either through a mask as a gas or through an intravenous line in liquid form.
Other drugs may be used to regulate vital functions - breathing, heart rate and rhythm, kidney function and so on. All are administered in precise amounts, and a patient's reactions to them are monitored.
Despite the technological improvements, anesthesia is not completely benign, and mistakes are still be made. Dr. Domino said the most common problems were drug errors, mistakes in the administration of fluids, and the misinterpretation of information delivered by the monitoring equipment.
But even these errors are preventable.
For example, Dr. Domino said, "Drug and fluid administration errors are prevented by vigilance and ritualized routines for labeling, checking and administering drugs."
"As in every area of medicine," she said, "there are technical limitations and adverse effects of drugs."
Most patients, even those careful about choosing the right surgeons, do not choose their own anesthesiologists, even though the skill of the anesthesiologist may be just as important.
In hospitals, the anesthesiologist is usually chosen by a system that takes into account call schedules, vacation times, and specialty - slightly different skills and expertise may be needed for pediatric surgery, neurosurgery, cardiac surgery or regional anesthesia.
In general, Dr. Domino said: "If the anesthesiologist weren't capable, the surgeon would refuse to work with him. So if your surgeon is comfortable with your anesthesiologist, then you can be comfortable as well."
PING
I thought this was about the Dem convention. Nevermind.
Thanks I'll feel better when I have surgery done, no plans for any yet!
ROFL Thats 'zactly what I thought when I saw the sidebar too!
I was going to type exactly the same thing.
Didn't Robin Cook write a book about this?
Been there, done that. Twice.
One surgery lasted the better part of twelve hours, and it felt like I just dozed off for a minute or two.
No doubt, a strange experience.
they put me out with versed good stuff hell i dont even remember flirting with the nurse or being driven home
YAWN. Old news. What's your point?
In the hands of an anesthesiologist, these drugs are great. I had a deep sedation for a breast biopsy, which was absolutely easy and stress-free, thanks to the anesthesiologist.
Conscious sedation is becoming the big thing in dentistry now, which concerns me because usually the dentist/oral surgeon must both monitor the patient and perform the procedure. I can never have conscious sedation again, due to an oral surgeon's incompetence. More people should consider the circumstances under which they are allowing themselves to be medicated with drugs that can easily cause respiratory depression and adverse psychological reactions.
EEG monitoring is a relatively new practice for anesthesiology, many folks on this forum seem to have enough surgical procedures and many are unfamiliar with the mortality rate for general anesthesia.
Who's Robin Cook?
Hey Joe, chill out. I'm glad to see this, cause I may have to go under the knife in the near future. Hope I don't but I'll know after Thursday. :(
I completed my training in Internal Medicine and Critical Care in 1980. EEG monitoring during surgery was standard practice by 1984. 20 years is "relatively new?"
Robin Cook is an Ophthalmologist turned mystery author. He wrote "The Terminal Man" and other medical novels.
Gas, get in here, and back me up you whippersnapper.
I finished my training in FP in 97. I never did any anesthesiology, but I never noticed any EEG monitors during surgical rotations. If EEG monitors are so standard, how come the following statement?
"The technique, called bispectral index monitoring, or BIS monitoring, is used in only about a quarter of operations in the United States, and much less elsewhere."
Thanks for the info. I probalby read one novel in the last 2 decades, Travis McGee's. I was unaware of the decreased mortality in general anesthesia, still quoting 1 in 10000.
I got Demeral and Versed for my recent colonoscopy. It was like taking a restful nap! And I 'came to' with not a care in the world!
What do you mean by respiratory depression?
They usually use synthetic opiates for analgesia. Opiate overdoses are almost always because the patient or drug abuser stops breathing.
Basically, when given in doses that are too large, the patient's respirations can slow dramatically or the person may stop breathing entirely. This can happen with the two main classes of drugs used in conscious sedation - benzodiazepenes and synthetic opiates.
I recieved benzodiazepenes for the most part, although there was one synthetic opiod in the "cocktail." The ER doctors were not sure which drug I had a reaction to, but it was likely one of the benzodiazapenes, since I was suffering from extreme anxiety and combativeness.
Conscious sedation is a great medium between full wakefulness and a general anesthetic, but IMO too many dentists/doctors use it in the office environment, without a trained anesthesiologist to administer the drugs. In a hospital or surgery center, with monitoring equipment, resuscitation equipment, and drugs to counteract adverse reactions, it is very safe and effective. People just need to be aware of the risks, and with all the ads and commercials for "stress free dental cleanings with twilight sleep!" it doesn't make it clear that it can be a serious problem for a small number of patients.
Thanks for your reply. I had this happen to me after a breast biopsy. I awoke suddenly in recovery & I wasn't breathing automaticaly. I had to force my lungs to expand. It about scared me to death. I felt paralyzed & could not speak. I don't know how I was able to get the attention of the nurse but she came over & put the oxygen mask on me & then I was OK. If I ever have surgery again I will discuss this with them beforehand.
If you look up the various adverse effects of benzodiazepines, you'll most likely find the term CNS depression, as in Central Nervous System. If you do the same for the various opiates, you'll find the term respiratory depression.
I remember you making some posts later that day....you had a helluva a buzz-on, Al! You were pretty funny...
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.