An Introduction to General and Local Anesthesia

Your Choices in Anesthesia

General anesthesia — for many people, it's the most frightening part of surgery. Being put to sleep and not being in full control of your own body is a scary concept, but being informed about anesthesia can put some of your fears to rest.

We can talk about anesthesia options for breast reduction surgery, but the actual choice may be out of your hands. The type(s) of anesthesia used in your surgery will be dictated by the procedure itself, where the surgery is performed, your general health, who is administering the anesthesia, and your surgeon's preferences. That's why it's important to thoroughly discuss anesthesia with him or her.

Why Do We Need Anesthesia?

Anesthesia is administered during surgery and other medical procedures for several reasons. It immobilizes the patient, prevents him or her from feeling pain, and controls many of the body's defensive mechanisms that have to do with pain. The fact is that while you can differentiate between a surgical incision that is necessary and an accidental cut, your body cannot.

As soon as your body is wounded or injured in any way — including surgically — it shifts into overdrive to protect itself. Your heart rate quickens, your blood pressure and breathing rate rise, and your body starts to repair the injury with a vengeance. This autonomic response by your body means you have no conscious control over it.

Anesthesia blocks these reactions until after the surgery is over and keeps your body from trying to overwork itself. It also helps block your memories of surgery, which are traumatic to the body. Healing is actually better and faster when you do not remember the pain that got you there.

Anesthesia works in five ways:

1. as an analgesic (pain reliever)

2. as an amnesiac (preventing memory of the experience)

3. to promote unconsciousness

4. to immobilize you

5. to reduce or eliminate your body's autonomic responses to trauma, such as tachycardia (increased heartbeat), increased breathing, and elevated blood pressure (hypertension).

Your Options in Anesthesia

There are several types of anesthesia, some of which are used in breast reduction surgery. Not all surgeons offer of all types of anesthesia.

The four main categories of anesthesia are:

• Local anesthesia

• Regional anesthesia (nerve blocks)

• Conscious sedation

• General anesthesia

Local Anesthesia

Local anesthetics stop pain in the immediate area of the surgery by numbing only the skin and underlying tissues. You've probably had a local anesthetic in your dentist's office or while getting stitches. Locals can be used in cosmetic surgeries such as rhinoplasty (nose job) in addition to sedation. However, they are rarely used for breast reduction.

Regional Anesthesia

As its name implies, regional anesthesia affects a region of the body without rendering the patient unconscious. The anesthetic is injected around a major nerve or the spinal cord, blocking sensation in a larger area than with local anesthetic injections. Regional anesthesia is also called a peripheral nerve block. Epidural and spinal anesthesia, which are often used in childbirth, are types of regional anesthesia. You will usually receive a mild sedative along with regional anesthesia to relax you.

In cosmetic surgery, regional anesthesia is often the choice for facial procedures, such as brow lift touch ups, lip reduction and augmentation surgeries, chemical peels, and liposuction under the chin. It is usually not used in breast reduction surgery.

Conscious Sedation

Usually administered by intravenous (IV) line, conscious sedation leaves you relaxed and drowsy but usually able to speak and respond to verbal cues. The medications for conscious sedation may also include muscle relaxants, pain medications, and drugs that can cause temporary amnesia. The mix of drugs can be customized to suit you and the procedure you are having.

An IV line is placed into a vein on the inside of your elbow or in the back of your hand. Once the needle is in the vein, it is pulled out and a small plastic tube (catheter) is left in its place. The catheter is taped to your skin to hold it in place. In most cases, a nurse or a staff member will attach a bag of fluid to the IV line, but the line is closed with a little roller device until the IV line is needed. The bag usually contains saline (sterile saltwater), to which medications can be added and dripped into you. The saline keeps you hydrated during surgery and postoperatively.

The effects of IV anesthesia are quick, usually felt very soon after the medications start to flow into you. You may feel a sensation of heat creeping into your veins and up your arm.

Additionally, you may receive oral sedatives, such as Valium (diazepam) or Xanax (alprazolam) by mouth an hour to an hour and a half before a surgical procedure. These drugs can help you relax and help alleviate anxiety by making you calm and drowsy. Depending on the dosage, you may even fall asleep.

General Anesthesia

General anesthesia is used for more extensive surgical procedures, or for any procedures where other forms of anesthesia are contraindicated. For example, small children often receive general anesthesia even for relatively minor procedures because it keeps them from moving during surgery. General anesthetics are usually given in the form of liquids via IV or inhaled gases or both.

General anesthesia affects your entire body, meaning there's a greater chance of side effects than with other forms of anesthesia. However, only a very small percentage of people have any problem with general anesthesia and most side effects are temporary. Because you are unconscious, your vital signs, such as your breathing and heartbeat, will be monitored.

Prior to going under general anesthesia, you may be given a sedative and medications either orally or by IV that interfere with your memory, so you may be sleepy before you get to the operating room. Afterwards, you may not remember being brought into the operating room, even if you were still awake at the time.

In the operating room, a breathing mask will be placed over your face and nose to administer the gas. Once you are unconscious, the anesthesiologist or the anesthetist will take away the mask and put a tube down your airway to continue administering the gas. This tube will also keep your airway (your lungs and throat) open, so your throat may be a bit irritated or sore, and both your throat and mouth may feel very dry after surgery is over.

Being nervous about undergoing anesthesia is very normal. If you are very anxious, you can ask your surgeon or the anesthesiologist for an anti-anxiety drug — Valium and Xanax are two that are often prescribed — that you can take the night before or the morning of surgery. Never take any medication before surgery without your anesthesiologist and surgeon knowing about it.

Why Shouldn't I Eat Before Surgery?

You must fast before anesthesia so that you don't have any undigested food in your stomach that might come back up. The danger is in inhaling some of the material into your lungs. Anesthesia can interfere with your normal reflexes, such as the reflex in your throat and airway that keeps you from choking.

Follow your surgeon's instructions about fasting very seriously. You will be told not to eat anything past a certain time the night before your surgery. If you must take a medication in the morning before your surgery (with your surgeon's approval), take it with only a few sips of water.

Who Will Administer the Anesthesia?

Anesthesia can be administered by an anesthesiologist, who is a medical doctor trained in anesthesia and pain management. An alternative would be a nurse-anesthetist, who is a nurse specially trained in administering anesthesia. You may see the letters CRNA after the person's name, which stands for Certified Registered Nurse Anesthetist. In some instances, the surgeon performing the procedure may administer some forms of anesthesia.

Anesthesia Side Effects

Coming out of anesthesia varies from person to person and from experience to experience. Even if you had anesthesia in the past and woke up well, you might be uncomfortable the next time, and vice versa. You may wake up gradually or abruptly, feeling hot, cold or a bit numb. You may feel nauseous or have a fit of crying or giggling. All of these reactions are completely normal. You may also feel confused and think you haven't even gone into surgery yet, since it won't seem like any time has passed.

There are several anesthesia side effects. Nausea is common. If you feel you are about to throw up, alert a nurse. He or she can give you a few sips of cool water or ice chips to help settle your stomach, and provide you with container in which to vomit. Some surgeons may give you an anti-nausea medication to decrease your risks of vomiting after your surgery. You probably won't be given anything to eat or drink yet.

The staff will be there to monitor you, so you may still be hooked up to machines that will track your breathing and heart rate. A small device clipped to a fingertip or earlobe may monitor the level of oxygen in your blood.

When I begin to regain consciousness, I feel like my peripheral vision is gone temporarily and everything is sort of pale. I get emotional sometimes, which is very normal.

If you are cold or shivering as you come out of anesthesia, let the staff know so they can cover you with a warm blanket.

Day surgery patients are kept in a recovery area until they're out of anesthesia. The staff will go over all your instructions to make sure you understand what you need to do when you get home and in the days that follow.

You will not be allowed to go home unaccompanied by an adult or to drive yourself home, so make arrangements for a responsible adult to do the honors after your surgery. Some surgeons insist that a responsible adult must stay with you overnight as well. If you do not have such an arrangement in place, your surgery may be canceled before it begins or you will be kept in the hospital overnight.

If there were any problems with your surgery, you may be kept in the hospital or surgical center overnight. Possible complications that might cause you to be admitted overnight include elevated blood pressure, severe nausea, or unusual bleeding. It's better to be safe than sorry in this type of situation.

Risks, Contraindications, and Complications of Anesthesia

Although the vast majority of patients have no problems with anesthesia, it is not risk free. The information here is not intended to scare you away from surgery, but rather to help you make an informed decision.

The best precaution you can take before having anesthesia is to prepare yourself by talking to your surgeon and to the person administering anesthesia. Both need to know all about your health, including any allergies you have, as well as any problems you have ever had with anesthesia. If other people in your family have had problems with anesthesia, mention that, too. Several health conditions — or the medications you take for them — can change the way your body reacts to anesthesia.

Serious problems with anesthesia are usually linked to the circulatory and respiratory system, so if you've ever had any serious breathing or lung problems, make sure that your surgeon and the anesthetist or anesthesiologist know about it. These conditions include asthma, chronic bronchitis, or allergies that cause you breathing difficulties. You may still be able to have surgery safely, but both your surgeon and whoever administers anesthesia should know in advance so that they can take precautions.

Smoking increases the chances that you may have breathing difficulties during surgery and impairs your ability to heal later. If you smoke tobacco or marijuana, you should abstain for a time before and after your surgery.

Make sure your surgeon and the anesthetist/anesthesiologist know if you have ever had any heart-related problems, such as a heart attack, heart failure, high or low blood pressure, a history of clotting problems or embolisms, or irregular heartbeat. Once again, you may have no problems with surgery or anesthesia, but precautions may be necessary.

Medication and Supplement Contraindications for Anesthesia

There are many medications and dietary or herbal supplements that you should not take before or after going under anesthesia. Make sure that your surgeon and the person administering anesthesia has a complete list of all the medications you take regularly, including vitamin and nutritional supplements and any herbal products. If you smoke marijuana or indulge in recreational drugs, say so.

If you take antidepressant medications, please advise your surgeon. Some antidepressants are monoamine oxidase (MAO) inhibitors (also known as MAOI) and they can intensify the effects of the anesthesia. This interaction can occur even weeks after you've stopped using an MAOI and could be a problem if your doctor is unaware of your medication usage. With advance notice, your doctor can make adjustments to your anesthesia.