1. Are there different kinds of anesthesia?
  2. What are the risks of anesthesia?
  3. What about eating or drinking before my anesthesia?
  4. Should I take my usual medicines?
  5. Could herbal medicines and other dietary supplements affect my anesthesia if I need surgery?
  6. What makes office-based anesthesia different?
  7. How is the epidural block performed for labor and delivery?
  8. Should I stop smoking before my surgery?
  9. Is there anything the anesthesiologist can do to prevent urinary retention?
  10. Are anesthetic risks increased with long surgeries?
  11. Are spinal anesthetics safe?
  12. Should all of my muscles be sore for a day and a half after breast surgery?
  13. I’m having problems swallowing and speaking long after surgery. What advice do you offer to help improve my problems?
  14. Should my throat be sore five weeks after surgery?
  15. Should my IV site continue to be sore and swollen three weeks after surgery?

Q. Are there different kinds of anesthesia?

A. There are three main categories of anesthesia: local, regional, and general. Each has many forms and uses.

In local anesthesia, the anesthetic drug is usually injected into the tissue to numb just the specific location of your body requiring minor surgery, for example, on the hand or foot.

In regional anesthesia, your anesthesiologist makes an injection near a cluster of nerves to numb the area of your body that requires surgery. You may remain awake, or you may be given a sedative. You do not see or feel the actual surgery take place. There are several kinds of regional anesthesia. Two of the most frequently used are spinal anesthesia and epidural anesthesia, which are produced by injections made with great exactness in the appropriate areas of the back. They are frequently preferred for childbirth and prostate surgery.

In general anesthesia, you are unconscious and have no awareness or other sensations. There are a number of general anesthetic drugs. Some are gases or vapors inhaled through a breathing mask or tube and others are medications introduced through a vein. During anesthesia, you are carefully monitored, controlled and treated by your anesthesiologist, who uses sophisticated equipment to track all your major bodily functions. A breathing tube may be inserted through your mouth and frequently into the windpipe to maintain proper breathing during this period. The length and level of anesthesia is calculated and constantly adjusted with great precision. At the conclusion of surgery, your anesthesiologist will reverse the process and you will regain awareness in the recovery room.

Q. What are the risks of anesthesia?

A. All operations and all anesthesia have some risks, and they are dependent upon many factors including the type of surgery and the medical condition of the patient. Fortunately, adverse events are very rare. Your anesthesiologist takes precautions to prevent an accident from occurring just as you do when driving a car or crossing the street.

The specific risks of anesthesia vary with the particular procedure and the condition of the patient. You should ask your anesthesiologist about any risks that may be associated with your anesthesia.

Q. What about eating or drinking before my anesthesia?

A. As a general rule, you should not eat or drink anything after midnight before your surgery. Under some circumstances, you may be given permission by your anesthesiologist to drink clear liquids up to a few hours before your anesthesia.

Q. Should I take my usual medicines?

A. Some medications should be taken and others should not. It is important to discuss this with your anesthesiologists. Do not interrupt medications unless your anesthesiologist or surgeon recommends it.

Q. Could herbal medicines and other dietary supplements affect my anesthesia if I need surgery?

A. Anesthesiologists are conducting research to determine exactly how certain herbs and dietary supplements interact with certain anesthetics. They are finding that certain herbal medicines may prolong the effects of anesthesia. Others may increase the risks of bleeding or raise blood pressure. Some effects may be subtle and less critical, but for anesthesiologists anticipating a possible reaction is better than reacting to an unexpected condition. So it is very important to tell your doctor about everything you take before surgery.

Q. What makes office-based anesthesia different?

A. There is one fundamental and very important difference between office-based anesthesia and receiving anesthesia in a hospital or ambulatory surgical center. The strict, well-defined standards and regulations that keep surgery and anesthesia very safe in hospitals and ambulatory surgical centers do not uniformly apply to physicians offices in the United States.

Q. How is the epidural block performed for labor and delivery?

A. An epidural block is given in the lower back. You will either be sitting up or lying on your side. The block is administered below the level of the spinal cord. The anesthesiologist will use a local anesthesia to numb an area of your lower back. A special needle is placed in the epidural space just outside the spinal sac.

Q. Should I stop smoking before my surgery?

I am a long term smoker over 50 yrs. I will be having a inguinal hernia repair in about 2 weeks. I have been told that my lungs may get worse before they get better if I quit smoking now and it may interfere with my breathing during my anesthetic and after surgery. Is this true? What do you suggest?

A. The bottom line is - quit smoking now! Your surgery represents a golden opportunity to do so. There is evidence that smokers who quit at or before surgery experience fewer symptoms of nicotine withdrawal and are more likely to succeed in their attempt to stop smoking long term. Although it may take 3 - 6 weeks for the lungs to recover from some of the effects of smoking, and you have only 2 weeks to go, there is still, on balance, benefit to you if you stop.

As always, you have to look at the benefits and the risks. During the first few days after stopping, some people will experience an increase in mucus production in the air passages of the lungs. Some people think this might increase the possibility of a lung complication but there is no published evidence that this is true.

On the other hand, the risks of a lung complication after a relatively minor operation such as inguinal hernia repair are rather low anyway. This is an operation that can be done without general anesthesia and intubation, which are associated with the lung complications you want to avoid. And there are also immediate physiologic benefits from stopping smoking, such as increased oxygen carried in the blood, and improvement in wound healing.

Some authorities, the most prominent of whom is Dr David Warner from the Mayo Clinic, believe that this is an important public health issue. Dr Warner heads a new American Society of Anesthesiologists task force which is looking at how to help people quit smoking at the time of surgery. You can find the materials that the ASA has developed to help you stop smoking at http://www.asahq.org/sitecore/content/Lifeline/Anesthesia-Topics/Why-How-to-Quit-Smoking.aspx. It's hard to do it on your own entirely, and the use of nicotine replacement therapy (NRT) - that is the nicotine patch or gum - can definitely help keep you off the cigarettes. Dr Warner concludes that NRT is safe, and probably effective for people trying to stop smoking around the time of surgery. Ask your primary care doctor to assist you with this.

Q. Is there anything the anesthesiologist can do to prevent urinary retention?

I am 75 year-old man. I have had surgeries for replaced knees, bladder tumors, and others, all with GA. After all the work is done and I am back home or in the hospital room I can never pee.

A catheter has to be put in always. A lot of hospital and Dr. office people have told me that the anesthesia has affected my bladder muscle and it won’t squeeze the pee out.

After 4-5 days when the catheter is taken out, I can pee again, but even then it takes a few days to get back to normal.

Is there anything the anesthesiologist can do so my bladder will not be so affected?

It is not a blockage like an enlarged prostate or anything (my urologist has confirmed that) but just the inability of the bladder to empty itself.

A. Thanks for your interesting question. Studies have shown that anesthesia is only one of several factors that can cause your problem, which is known as “urinary retention”. But there is a perhaps understandable tendency among some doctors to blame anesthesia for anything that goes wrong after surgery! As anesthesiologists, we are accustomed to this phenomenon and usually are able to make light of it with our surgical colleagues.

Spinal or epidural anesthesia is a well known cause of urinary retention – in these cases, the retention usually lasts only a few hours and can be remedied by emptying the bladder with a catheter during that short period of time while the anesthetic wears off. However, specific anesthetic agents used in premedication and in general anesthesia seem to have little to do with urinary retention. Similarly, analgesic (pain) medications probably have little effect.

Surgery of the pelvis or urinary tract can cause urinary retention through inhibition of bladder reflexes caused by surgical manipulation. Another factor that can prevent the bladder from emptying normally is excess fluid administration resulting in bladder distension. Pain and anxiety can also contribute to the problem. The effects of non-anesthetic medications can play a part – the medications that do this, such as anticholinergic medications, have effects on parts of the autonomic nervous system which control bladder emptying. Inability to stand or sit after surgery has been found to be a common cause of retention. In older men, enlargement of the prostate gland frequently leads to urinary retention.

Unfortunately, patients who have had urinary retention, like yourself, are at particularly high risk of having this happen again. Individuals with this problem often have an abnormal voiding history before the surgery, which may indicate the presence of an “occult” (silent) neuropathic (nerve) or obstructive bladder disorder. The fact that you have previously had surgery on your bladder makes me suspect that this is case – however this is only speculation, and you should discuss this in detail with your urologist. Your urologist may be able to do special tests to determine whether there is a subtle bladder problem which is your predisposing factor for postoperative urinary retention.

Regrettably therefore, there is probably not much your anesthesiologist can do to prevent this from happening again. However, you should definitely discuss this problem with both your surgeon and your anesthesiologist before any subsequent surgery to try and address correctable factors, such as those I’ve mentioned, before, during and after the surgery.

Q. Are anesthetic risks increased with long surgeries?

I will be having breast surgery and reconstruction soon. My HMO has plastic surgeons who can do a bilateral mastectomy with a Deep Interior Epigastric Perforator (DIEP) flap reconstruction in 12-18 hours. An outside physician can do the same surgery in 6-8 hours. Can you tell me what greater risks would be involved in being under anesthesia for 12-18 hours versus 6-8 hours? I am 52 years old. Thank you.

A. Thanks for your question. If you are a healthy individual without other medical problems, your risk of an anesthesia complication from a mastectomy and reconstructive surgery is rather low. I cannot comment on the risk of the surgical procedure itself, which is probably the most important issue in your case. I would advise you first of all to get some clarification from your surgeons as to why there is such a big time difference between the two procedures you describe. It is possible that the shorter procedure (6-8 hrs) is actually a different operation in some way. For that kind of information you should speak directly with your surgeons. The best person with whom to discuss the risks of anesthesia is an anesthesiologist who has had the opportunity to review your medical records, take a full medical history and examine you, and who is aware of the nature and extent of the planned operation.

Having said all that, I am not aware of any evidence that the duration of general anesthesia by itself increases the risks of anesthesia complications. Studies of anesthesia-related risk have shown correlation with other factors, like:

  1. Your general medical condition especially problems like diabetes, heart or lung disease, malnutrition or obesity,
  2. Your functional status, that is your ability to tolerate at least moderate levels of physical activity.

Obviously, anesthetic outcomes are also related to the skill and experience of the anesthesiologist or anesthesiology team that is taking care of you. The anesthetic needs to be tailored to your medical condition, to the surgery itself, and wherever possible, to your individual preferences. As with other medical outcomes, having your surgery in a center that performs larger numbers of the procedure is more likely to result in a good outcome than having it in a hospital does only a small number each year.

Q. Are spinal anesthetics safe?

I need a total hip replacement and the surgeon I’ve seen says he uses spinals for surgery. I’ve heard bad things about this and wonder how safe that kind of anesthesia is.

A. Thanks for your question. You can rest assured that spinal anesthesia is a safe choice for hip surgery. Many patients when offered this type of anesthesia are concerned about serious side effects, such as paralysis, and also about troubling but less dangerous side effects, such as headache. There seems to be a common, although false, perception that these complications occur often. In fact, spinal anesthesia has a long track record of safety, with a rate of serious complications (low!) about equal to the rate of major problems with general anesthesia (also low!). Studies that have looked at the overall outcome of spinal and general anesthesia for hip surgery have not found a completely convincing advantage of one over the other, and therefore both types of anesthesia are commonly used. In our hospital, at least half of the hip replacement surgery is done with spinal anesthesia. Among the reasons it is favored, include: (1) more rapid recovery of mental function, (2) the lack of need for insertion of breathing tubes, (3) the lower incidence of nausea or vomiting, and (4) the prolongation of anesthesia after completion of surgery, which means a longer pain free period. Paralysis after spinal anesthesia is very rare. The number of patients who develop a headache is also quite low – in expert hands and using appropriately sized (small) needles, fewer than 1% or so of patients should have a headache. Although a “spinal headache” is troublesome, it is not life-threatening. Not all patients are candidates for spinal anesthesia. We do not offer this technique to patients who are at risk for internal bleeding problems or to patients with infection in the area where the needle is inserted. In our hospital, we try to offer a realistic explanation of the different anesthetic techniques, their risks and benefits. Assuming there is not an absolutely compelling reason to choose a particular technique, we usually allow the patient to make a choice. It is best for you to have this discussion with your anesthesiologist, the physician who will be responsible for this aspect of your care.

Q. Should all of my muscles be sore for a day and a half after breast surgery?

I had breast surgery a few years ago and will have to undergo a similar procedure again. I experienced severe muscle and joint pain 8 to 10 hours after the surgery and the pain lasted for about 36 hours.

I had never experienced anything so painful before, and I am more than a little concerned about this happening again. What accounts for this pain?

A. Thanks for your question. The severe muscle and joint discomfort you experienced after breast surgery is known as "postoperative myalgia". This is a fairly common, quite distressing, but rather interesting condition. It usually appears on the first day after surgery, is often described as feeling similar to the pain one might suffer after unaccustomed physical exercise, and is usually located in the neck, shoulder and upper abdominal muscles. There are a few theories about the cause of postoperative myalgia, but it is usually attributed to the use of a muscle relaxant drug called succinylcholine. Hence this is sometimes referred to as "scoline pain".

Although the problem of postoperative myalgia has been recognized for many years, the exact way in which succinylcholine causes this muscle pain is not fully understood. Most believe that it is due to uncoordinated contraction of muscles that occurs a few seconds before the muscle relaxation that is the desired effect of the drug.

It is also not clear how best to prevent scoline pain, short of avoiding the use of this drug altogether. It is natural to ask then why we continue to use this medication, and the reason is that succinylcholine, despite a few significant side-effects, is a very reliable and quick-acting muscle relaxant that helps the anesthesiologist "secure" the airway (place a breathing tube).

Myalgia from succinylcholine is most common in young female patients, especially those undergoing ambulatory surgery (going home the same day as the surgery). The incidence of myalgia with succinylcholine ranges widely - in some reports it's as low as 1.5% but can be as high as 80 - 90%. To add to the mystery, some patients experience myalgia even when they are not given succinylcholine at all!

Naturally you would like to avoid this very unpleasant experience at your forthcoming surgery. The good news is that there are other muscle relaxant drugs than can almost always be used instead of succinylcholine. This will not guarantee that you do not have the myalgia again but probably makes it much less likely.

If the use of succinylcholine cannot be avoided, (this is rare), there are methods for decreasing the incidence and severity of the muscle pain, such as giving a very small dose of another muscle relaxant before the succinylcholine, or by giving a local anesthetic medication called lidocaine.

Typically the pain lasts 2 or 3 days and it can be quite severe, as you've described. Fortunately it does go away without specific treatment. Standard pain medicines, such as acetaminophen can be prescribed.

You or your anesthesiologist may be able to obtain the records of your previous anesthetic and hospital stay. This will supply clues about what happened to you during your last surgery. Be sure to discuss your concerns with your anesthesiologist, whose job is to evaluate you thoroughly and come up with a plan to provide you with a safe anesthetic, with minimum side-effects. Good luck!

Q. I’m having problems swallowing and speaking long after surgery. What advice do you offer to help improve my problems?

Over a period of 10 yrs., I’ve had 3 long cervical and 1 long lumbar spinal fusion. My voice has changed; sounds rasping when I’m tired; I have problems swallowing; learned to Heimlich myself when food gets stuck, and even have sudden muscle spasms trying to swallow saliva and think I’m going to choke to death. One surgeon said all the tubes put in during surgery could affect vocal chords, muscles, and nerves. What advice or help is there to relieve these problems? Does any of this also cause me to slur my words when I’m tired? I’d truly appreciate your insight. Many thanks.

A. I’m sorry to hear of your difficulties. Recent studies are showing that endotracheal intubation – that is, the insertion of a plastic breathing tube into the windpipe – can cause minor damage to the vocal cords in a surprisingly high number of patients. This can occur even when the intubation is performed by an expert and appears to go absolutely smoothly.

When the larynx (voice box) is examined with special instruments after apparently routine intubation, bruising or swelling of the vocal cord structures is often seen. This minor damage causes hoarseness which, fortunately, almost always improves over a few days.

Unfortunately, endotracheal intubation is necessary for most surgeries on the spine, and we have not yet discovered ways to protect our patients from these minor injuries. More severe or permanent damage to the larynx (voice box) from endotracheal intubation is quite rare.

Risk factors may include rheumatoid arthritis and the use of steroid medications. It is not clear whether damage to the voice box increases with the duration of the surgical procedure, but in someone who has had several long procedures, the chances of injury are probably higher.

The symptoms other than hoarseness that you mention – problems swallowing, food obstruction, muscle spasms and slurred speech, do not sound like they are connected to the tubes you’ve had placed during surgery. They raise the possibility of a neurologic (nerve) problem, or a throat disorder, that might possibly be related to your previous surgical procedures but may also have nothing at all to do with them. I would strongly advise that you seek a specialist referral to an appropriate professional, such as an ear, nose and throat doctor or a neurologist.

Q. Should my throat be sore five weeks after surgery?

I had laparoscopic surgery 5 weeks ago for a hernia. Since that time, I had some minor nausea with severe hoarseness in my voice with a sore throat. The surgery itself went fine. The voice hoarseness and sore throat is still there and now I have vomited a small amount of blood one time. I had not eaten that day, and the blood was pink with saliva only. Could this be something caused from the anesthesia during surgery? I am not taking any medications at this time. Thank you for any help.

A. A sore throat after general anesthesia is not uncommon, occurring about 20-30% of the time. In most cases it is mild, and gets better without treatment over a couple of days. Similarly, nausea after general anesthesia is quite common, especially if you are young, female, have had postoperative nausea or motion sickness before, a long anesthetic, and if you have had certain types of surgery, such as breast operations, eye or ear procedures, shoulder operations and others.

It is certainly unusual that you would have your sore throat, or nausea, 5 weeks after the anesthetic. Coughing or vomiting blood is quite an alarming symptom so I'm sure you're worried. It doesn't necessarily represent something nasty but should definitely be investigated.

Recent studies have shown that even when the intubation goes very smoothly, the passage of the breathing tube into the larynx (voice-box) and through the vocal cords often causes minor trauma - bruising. In rare cases, the small cartilages of the larynx can be significantly damaged, and this can take quite a long time to recover. The main symptom in this case is hoarseness. More serious injury to the voice box, or to the nerves that supply it, is also possible.

Very rarely, the sore throat can be a sign of something even more ominous - a tear in the lining of the throat that if extensive can lead to severe infection, called mediastinitis. This can happen if the intubation (insertion of breathing tube) is traumatic for some reason, and if the lining of the throat is abnormally thin (e.g. elderly people, or those taking steroids) but this will usually happen over the few days immediately after the operation, not 5 weeks later.

It is possible that your larynx was injured during the intubation or the course of the anesthetic. For this reason you should call your doctor and ask for a referral to an ENT (Ear, Nose and Throat) doctor who can do a thorough examination of your throat. It would also be a good idea if possible to make contact with your anesthesiologist. He or she will be keen to know that something has happened that might be related to anesthesia care and I imagine will be interested in helping you get diagnosed and appropriately treated.

Q. Should my IV site continue to be sore and swollen three weeks after surgery?

Three weeks ago today I had a tooth pulled by an Oral Surgeon and they ended up having to give me an IV to knock me out. The Oral Surgeon put the IV in the back of my hand. I have been having pain in my hand ever since I had the IV. Two week after the IV I noticed that the vein in my hand was swollen and it hurt up into my wrist. I did call the Oral Surgeons office and I did go see her. She said that there could be a possibility that it could be phlebitis or a blood clot. She told me to use an anti-inflammatory and to put warm compresses on my hand and to come back to see her in 3 days. I have another appointment with her today. I would like to know if something like this normal after having an IV. I did contact my Internal Medicine doctors office and they told me to see the Oral Surgeon today and see what she says and then to call their office back. Is this something that is normal or could it be a serious problem.

A. Thanks for your question. Phlebitis is a term that means inflammation of a blood vessel. Phlebitis occurs quite commonly after the insertion of intravenous catheters ("IV"). The exact frequency of phlebitis is anywhere from 2.5 to 45% or more. There is a wide variation because it depends on how phlebitis is defined, as well as the place the IV is inserted, the duration that the IV has been in place, the type of material that the IV is made of, the length of the IV catheter, and on the existence of other disorders as diabetes. Phlebitis can also be associated with the formation of a blood clot in the vein. In more serious cases the site can become infected. If infection develops, the infection can be spread throughout the body. It would be very unusual for an IV placed in a hand, for a short period as you describe, to develop a serious infection. One sign of infection is the presence of enlarged lymph nodes under the arm on the affected side. Because of the risk (though small) of serious complications, you should definitely make sure to see your surgeon for the follow-up appointment. Hopefully the standard conservative treatment you mention will be successful.

This information is from the American Society of Anesthesiologists