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There are four main categories of anesthesia used during surgery and other procedures:
- – General anesthesia
- – Regional anesthesia
- – Sedation / monitored anesthesia care
- – Local anesthesia
Sometimes patients may choose which type of anesthesia will be used.
Types of Anesthesia
Your physician anesthesiologist will discuss the types of anesthesia that would
be safe and appropriate for the operation or procedure you need, and will explain your options clearly. Below, you will find more details.
General anesthesia is what people most often think of when they hear the word “anesthesia”. During general anesthesia, you are unconscious and have no awareness or sensations. Many different medications may be used during general anesthesia. Some are anesthetic gases or vapors that are given
through a breathing tube or a mask. Some medications are given through the IV to induce sleep, relax muscles, and treat pain.
Our physician anesthesiologists work with each patient individually to determine which combination of medications is best, depending on your state of health, your other medical conditions, the medications you take, any allergies, and the type of surgery you are having.
The most frequent side effect of general anesthesia is drowsiness afterward. This typically goes away within the first hour or two after surgery ends. Some patients may experience a sore throat or nausea. If you have a history of motion sickness or nausea after prior operations, be sure to mention that to your physicians and nurses, as you may need medication before surgery to help prevent nausea afterward.
Serious reactions to general anesthesia are exceedingly rare. Your anesthesia team has immediate access to emergency medications to treat any kind of reaction, and will monitor your vital signs continuously throughout surgery and recovery.
Regional anesthesia makes an area of the body numb to prevent the patient from feeling pain. It can completely block sensation to the area of the body that requires surgery. The anesthesiologist injects local anesthesia (numbing medication) near the cluster of nerves that provides sensation to
that area.
Two quite common types of regional anesthesia are spinal and epidural anesthesia. Either one may be used for childbirth, or for orthopedic procedures such as total knee and total hip replacement.
Sometimes, an epidural catheter is left in place to allow continuous pain relief to be given for one or more days after surgery. This is common after surgery on the chest or abdomen, even when general anesthesia is used during the operation.
Nerve blocks are another type of regional anesthesia that can provide pain relief to a smaller area, such as an arm or leg. Examples include femoral nerve block to numb the thigh and knee, or a brachial plexus block to numb the shoulder and arm.
Having regional anesthesia for surgery does not mean that you have to be completely awake. Many patients prefer to receive sedation so that they can relax and doze off during the procedure. Sometimes regional anesthesia is used in combination with general anesthesia for major surgery on the chest or abdomen. This technique has the advantage that patients do not need as much opioid pain medication after surgery.
Sedation, also known as “monitored anesthesia care”, is what people have often referred to in the past as “twilight”. Medications are given, usually through an IV, to make the patient feel drowsy and relaxed. Different levels of sedation are possible, depending on the type of procedure and the
patient’s preference.
structions. With moderate sedation, the patient may doze off but awakens easily. Deep sedation is nearly the same as general anesthesia, meaning that the patient is deeply asleep though able to breathe without assistance. Deep sedation with a medication called propofol is often used for procedures such as upper endoscopy or colonoscopy.
Local anesthesia is the term used for medications such as lidocaine that are injected through a needle or applied as a cream to numb a small area. Local anesthesia alone may provide enough pain relief for limited procedures such as sewing up a deep cut or filling dental cavities. It is often used along with sedation during minor outpatient surgery. At the end of many operations, the surgeon may inject local anesthesia to provide additional pain relief during recovery.
Preparing for Surgery and Anesthesia
If you are getting ready for surgery or any procedure, here are some easy steps to make the process smoother.
Follow your dietary instructions
Be sure to follow the instructions you have received about when to stop eating and drinking. The usual advice is to stop eating solid foods 8 hours in advance of your scheduled arrival, and to stop taking clear liquids 2 hours in advance.
Most medications should be taken on your usual schedule the day before your procedure. It is usually best not to take any medications by mouth within 8 hours of your scheduled arrival time. Many medications may cause stomach irritation or nausea if taken without food.
For some medications, though, the issue may be more complicated! Our goal is to tell you which medications need special consideration before anesthesia and surgery, so that you can ask your physicians the right questions in advance.
The physician who prescribes your medications may need to speak directly with your surgeon or the physician who will perform your procedure. This may be the best way to make the decision of which medications — such as aspirin — should be stopped before surgery, and which should be continued for your safety.
Please bring a list of all your medications with you when you come to the hospital.
Here are some of the medications that need special consideration:
Medications in the ARB category (such as Cozaar, Diovan, and Benicar) or the ACE-inhibitor category (such as Lotensin, Vasotec, and Zestril) may cause your blood pressure to become low during anesthesia. If you are on any of these medications, it is usually better NOT to take it on the day
of your procedure. Discuss with your doctor whether you should or should not take a dose the night before surgery.
Medications in the beta-blocker category (such as Coreg, Lopressor, and Tenormin) may have a protective effect on your heart. You should take these medications on your usual schedule with a sip of water unless your doctor specifically advises you to stop.
Please check with your doctor about whether you should take fluid pills such as Lasix or hydrochlorothiazide on the day of surgery, as they may cause dehydration especially in hot weather.
We will check your blood pressure before surgery, and if you need more medication to treat high blood pressure, we will give it through your IV.
If you are on insulin, please ask your doctor for specific instructions about taking insulin the night before and/or the morning of surgery. You will probably be advised to lower the dose since you will not be able to eat breakfast.
If you take other medications (pills) for diabetes, it is usually best to take your evening dose the night before surgery, but skip the morning dose on the day of surgery.
When you arrive at the hospital or surgery center, please let your team know that you are diabetic. We will check your blood sugar right away to make sure that it is at a safe level.
Medications that stop blood from clotting such as Coumadin, Eliquis, Pradaxa, and Plavix should usually be discontinued at least several days in advance of surgery. Please follow your surgeon’s instructions about when to stop these medications.
Patients are often advised to continue taking low-dose aspirin for life if they have poor circulation, heart problems, or stents to improve blood flow. If aspirin is stopped, you could be at increased risk of a heart attack or other complications. On the other hand, taking aspirin may increase the chance of bleeding during delicate surgery such as operations on the brain or spine. Your surgeon and the physician who prescribes your medications should agree on whether it is best for you to stop low-dose aspirin or continue taking it.
If you are in pain and are taking opioid pain medications such as Vicodin or Percocet, it is fine to continue taking your usual dose with a sip of water until two hours before surgery.
If you are using a fentanyl patch, it is fine to leave it in place. Please let your anesthesia team know exactly when you last changed it.
NSAIDS (nonsteroidal anti-inflammatory medications) such as Advil or Aleve are usually not recommended before surgery, as they may increase the risk of bleeding. Your surgeon will advise you if you need to stop taking these medications, and how many days before surgery they should be stopped.
If you are taking Suboxone or methadone for chronic pain, please make sure that your pain doctor knows you are having surgery. It may be best for you to stop Suboxone and switch to a different kind of pain medication before surgery. If you need a consultation with a pain specialist before surgery, please ask your doctor to arrange one with our Pain Medicine service. One of our physician anesthesiologists who specializes in pain medicine will be happy to meet with you and develop a plan for pain control after surgery.
Many patients take alternative or herbal medications without realizing how potent they can be. These medications are not regulated by the Food and Drug Administration. St. John’s Wort and ephedra, for example, should be avoided before anesthesia because they alter the effects of anesthesia medications. Garlic, ginger, and gingko biloba may increase the risk of bleeding during surgery.
Please watch this video from the American Society of Anesthesiologists if you take herbal medications, or if you would like further information about herbal medications and anesthesia.
Rules about when to stop eating and drinking are created to keep patients safe! It is especially important for every patient to have an empty stomach before any surgery or procedure that requires anesthesia, for two reasons:
- – To prevent nausea
- – To keep any food or liquid from getting into the lungs.
Adults and teenagers over the age of 12 may have solid foods and dairy products until 8 hours before their scheduled arrival time at the hospital or surgery center. Please do not drink any alcoholic beverages within 8 hours of your scheduled arrival time.
You are encouraged to drink clear liquids — NOT milk or dairy products — until 2 hours before the time you are scheduled to arrive at the hospital or surgery center. Staying hydrated is good for you, and it is especially important in hot weather!
Clear, see-through liquids include:
- – Water
- – Clear fruit juices such as apple juice and white cranberry juice
- – Plain tea or black coffee (NO milk or creamer)
- – Clear, electrolyte-replenishing drinks such as Pedialyte, Gatorade, or Powerade (NOT yogurt or pulp-containing “smoothies”)
- – Ensure Clear or Boost Breeze (NOT the milkshake varieties)
Certain procedures may require special preoperative fasting instructions. If you receive separate instructions from your surgeon or the physician performing your procedure, please follow those carefully. For example, patients undergoing colonoscopy, bariatric (obesity) surgery, or colorectal
surgery may be instructed to be on a clear liquid diet for a day or more prior to surgery. Please contact your surgeon’s office with specific questions.
Many patients recover more quickly from surgery today and return home sooner than they used to, thanks to better pain management and other care improvements. This progress is part of a comprehensive program and a joint effort between the Department of Anesthesiology and Perioperative Medicine and the Department of Surgery.
Narcotic and opioid pain medications — such as morphine, hydromorphone (Dilaudid), and hydrocodone (Vicodin, Norco) — often are used to manage postoperative pain, but they may cause opioid-induced constipation, or “OIC”. They slow down the return of bowel function after surgery. If
patients are unable to eat or drink, they cannot return home.
The physician anesthesiologists use regional anesthesia techniques for many patients, such as epidural anesthesia or a special, ultrasound-guided nerve block for abdominal incisions called a
“transverse abdominis plane” or “TAP” block. Patients still receive general anesthesia for their operations, but the regional anesthesia controls pain long after surgery ends. Many patients need no opioids at all during surgery, and need much lower doses afterward.
It is a relief to many patients to know that they will not need large doses of narcotics after surgery. They won’t be at risk of becoming addicted to pain medications, and will be spared the other side effects of opioids such as grogginess and nausea.
Other components of our enhanced recovery program include:
- – A best-practice protocol to prevent nausea and vomiting
- – The use of minimally invasive surgical techniques with small incisions whenever possible
- – “Multimodal” pain relief, using non-opioid pain medications
No matter whether surgery is a minor outpatient procedure or a major operation
requiring days in the hospital, patients and family members want to know what to expect in terms of pain afterward. Most of us will experience some pain or discomfort after a procedure, but it should never be unbearable.
Your anesthesiology team manages pain relief during the procedure and in the immediate period afterward while the patient is in one of our Post-Anesthesia Care Units. If an epidural or a continuous nerve block is part of the pain management plan for a patient who is in the hospital, we can be reached every day and adjust pain medication, as necessary.
Our goal is for every patient to be comfortable enough to take deep breaths and move as needed, because this helps the recovery process. We also want to use different kinds of pain relief strategies, also called “multimodal” pain relief, to reduce the need for opioid medications. Your comfort and safety are our chief concerns.
Opioid medications, also known as “narcotics”, are powerful medications used to control pain. The earliest of these medications was opium, which has been extracted for more than 5,000 years from the opium poppy. Today, we have many different opioid medications available, including morphine, eperidine (Demerol), hydromorphone (Dilaudid), and oral medications such as hydrocodone (Vicodin) and oxycodone (Percocet).
While opioids are useful medications for severe pain, they can cause addiction and they have been responsible for thousands of deaths by overdose during America’s current opioid epidemic. They may also be associated with unpleasant side effects including nausea and constipation.
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