Welcome!

We will look after you for your forthcoming eye surgery, whether it be for a cataract, a pterygium, or another procedure.

This blog is to give you a few instructions...

Fasting Instructions:

You should not eat for six hours prior to your surgery. You can continue to drink water (and water only) up until 2 hours prior to your surgery. After that you should not drink and eat at all until your surgery.

Tablets and Medicines:

preoperative surveyor contact medirectly. We often leave you on the drugs that thin your blood, at the discretion of the ophthalmologist, but we do need to know you are on them as it can affect how we do your procedure. If you are on insulin we usually followthese insulin instructions.

Do not hesitate to contact me if you are not clear on these instructions.

Quick Link: http://tinyurl.com/eye-fasting

This blog explains a few of the basic ideas behind the ways in which anaesthetists assist you having a caesarean section; it is general in nature (see disclaimer below), is not medical advice, and may or may not be pertinent to your specific circumstances.

It is the first part of a multi-part blog that discusses the anaesthetic techniques used to assist you in having a safe and comfortable journey through to the operative delivery of your baby.

Overview:

Having a caesarean section is not an uncommon experience with at least 1 in 5 women in Australia delivering their baby through this means, and with about two-thirds of these being unexpected emergency deliveries. This means that even if you’re planning to have a conventional vaginal delivery then its still worth reading this brochure so you’re more emotionally and intellectually prepared if the unforseen occurs and you are suddenly in the operating theatre being prepared for an urgent caesarean section.

Fortunatley, the most usual situation is that your caesarean is planned in advance, and this is called an “elective caeserean section". There are multiple reasons why this may be the case ranging from maternal choice (“caesarean on request”) through to a range of medical indications, e.g. your baby being in an unfavorable position for a vaginal delivery in the later stages of pregnancy. The decision to have a caesarean is one shared by yourself and the obstetrician and usually that decision is already made by the time the anaesthetist is involved in your care. An elective caesarean should always occur during normal working hours and not in the middle of the night.

The more unusual situation is that there is an unexpected change in either your baby’s status or your own, and an "emergency caesarean section" is then indicated; this can range from a prolonged labour where the chances of a vaginal delivery are becoming increasingly unlikely through to an abrupt change in the health status of your baby making an urgent delivery necessary. An emergency caesarean can occur at any time of day, and, unfortunately for all concerned, is very often in the middle of the night!

Anaesthetic Choices:

There are a range of techniques that anaesthetists use to facilitate this surgery, which generally fall into the category of being “asleep” or awake.

1. The Spinal - this is the most common method used for a caesarean section and involves placing a small needle into the bag of fluid that surrounds your nerves in the lower part of your back. A small amount of anaesthetic is then injected into the bag which numbs all the nerves that carry pain up to about the level of your chest. It is a very efficient, generally safe, and fast method of making you comfortable for surgery although it lasts only for a very defined period of time, usually no more than a few hours.

2. The Epidural - this is often a method used if you’ve already had an epidural put in during your attempt to deliver your baby vaginally, but then for whatever reason have to go an have an emergency caesarean section. There are situations where it might not be appropriate, such as if the epidural hasn't been working very well during your labour (e.g. is one sided), or if we need to get the baby out really really quickly, as it can take a little for the epidural to work with the stronger medicine we use for surgery rather than just for pain relief, and we might just not have time. Sometimes we use epidurals for elective caesarean cases as well, for example if you are have a lot of body weight and the operation is likely to take a long time, then a spinal will probably run out before we’re finished, and an epidural may be the preferred choice.

3. Combined Spinal-Epidural - this is a clever little combination of the above two methods; which slightly increases certain risks due to having to use two needles instead of one, but comes with a number of advantages such as taking effect very quickly (the spinal part) but allowing us to continue to give medicine for as long as the surgery is taking place (the epidural part).

4. A General Anaesthetic - this is simply going to sleep for the operation and doesn’t involve any needles in the back, but will involve needing a breathing tube to breath during your operation and a range of medicines to keep you asleep and guide you through the surgery.

Side-Effects & Complications:

Generally it is pretty apparent to the anaesthetist what is the safest option for you, and that will usually, but not always, be a needle in the back (spinal, epidural, combined spinal-epidural) rather than going to sleep (a general anaesthetic).

There are many reasons for this decision, but a major factor is that we know that a lot of medical evidence is available that indicates it is safer for most women to have the needle in the back than to go to sleep, although in an absolute sense both are usually quite safe procedures, barring any unexpected complication. One of the problems with pregnant women is that the vast changes that occur during pregnancy simply make it a lot harder for the anaesthetist to place the breathing tube and to guide the asleep pregnant women’s response to a general anaesthetic.

The risks of the needle in the back, whether that be a spinal, epidural, or combined spinal-epidural, have been covered somewhat in our brochure on epidurals

Having said that, there are some very common side-effects that are helpful to discuss prior to your caesarean section if only to reassure you that they are common, and to discuss what we can do about them ahead of time.

Firstly, it is not unusual to have some mild and transient shaking immediately after a spinal anaesthetic, and whle this tends to resolve quite quickly it can be disconcerting. Of course, you might just be cold, as the operating theatres are very cool, and either way we’ll give you a warm blanket.

Secondly, some nausea occasionally occurs after a spinal. Again, while nausea may simply be anxiety, it’s more likely to be the brain’s response to the transient lower blood pressure that sometimes occurs after having a spinal. However, you must tell your anaesthetist that you are feeling nauseous, as we prefer you to be at your normal blood pressure, and without nausea, and can generally we can solve these problems quickly with some medication to normalise your blood pressure. If you still feel nauseous, even when everything seems to be going well with a normal blood pressure, then we'll use some other clever little drugs which will usually solve the problem.

Thirdly, occasionally some people complain of being short-of-breath; this is usually due to the spinal reducing the power in some of your chest muscles of breathing with the spinal, which is not unexpected; be reassured that the diaphragm, the main muscle of breathing, is very unlikely to be affected. This shortness-of-breath tends to quickly pass but we can always give you some oxygen which seems to subjectively improve your situation even though usually our monitors say that you're doing fine either way. Fortunately most of these problems are very transient, and are well over by the time the baby is delivered.

It's important to communicate to your anaesthetist if any of these problems occur, or if you have any other concerns, as while "common things happen commonly", and are usually easily solved, there may always be a chance that something more serious is going on. We rely on you to communicate to us any problems.

Remember that your anaesthetist is highly motivated to ensure you have a comfortable and safe journey to the end of your anaesthetic!

Our next blog will continue our exploration of caesarean sections, and specifically discuss post operative pain relief…

Disclaimer: This article is not medical advice and is general in nature. Your specific circumstances should be discussed with your obstetrician and anaesthetist who are responsible for these decisions on your behalf; we take no responsibility for the accuracy or otherwise of information contained in this article.

Dr Brett Wells is the foundation Director ofElite Anaesthesia; an organisation whose main mission is to deliver the best possible care to patients both before, during, and after their surgery.

Quickref: http://tinyurl.com/drblog1

The specific technique used to anaesthetise you for surgery depends on both you and the specific planned procedure: one size does not fit all, which is part of the art of anaesthesia.

Generally you will be taken to the anaesthetic bay, a small room outside the operating theatre, where Dr Wells will review your records, ask questions, perform an examination, and discuss with you the most appropriate anaesthetic for the envisioned procedure. This can range from being awake with a specific nerve block so that you are comfortable, through to sedation for a small procedure, up to a general anaesthetic. A range of techniques ranging from blocks to the eyes, the arms, the legs, the tummy, or a temporary paralysis from the waist down may be applied dependent on the situation. The variety of methods available is one reason why the training program for anaesthetists is so very long, but also why anaesthetic services in Australia have a proud record of safety and success.

This article is reproduced from the Las Vegas Review Journal 27 March 2016 - see orginal article

There’s nothing short of an everyday miracle — a medical, pharmacological, technological miracle — unfolding in an operating room at University Medical Center of Southern Nevada.

Recently, on an otherwise ordinary Friday morning, Dr. Keith Blum, a neurosurgeon, will be removing a portion of skull that is pressing on a boy’s brain.

The miracle: The boy will feel nothing during the operation and remember nothing about it afterward.

Then there’s this: The youth won’t die despite the stress to his body caused not just by the procedure itself but also by the effects of the anesthesia necessary to perform it.

And for that, credit Dr. Samson Otuwa, the scrub-suited guy sardined in amid an array of monitors and IV lines and cords that make his work space more resemble the cockpit of a jet than an operating room.

Otuwa is a physician anesthesiologist. While Blum is performing surgery, Otuwa will keep the boy alive but deliberately unconscious, during a span of time when, without Otuwa’s nonstop attention, the boy surely would die.

Anesthesia is such a routine aspect of modern medical practice that it’s easy to forget how amazing, and how bizarre, it really is. And, while patients know and certainly appreciate what surgeons and nurses do during an operation, the role of the anesthesiologist — someone who the patient probably met just before their operation and may see again only briefly in the recovery room — often is taken for granted.

Until the bill arrives, anyway.

Otuwa, who specializes in pediatric anesthesia — he estimates that kids make up about 20 percent of his practice — describes his job in a way most patients would find nothing short of frightening.

General anesthesia — the type of anesthesia that, in contrast to, say, local or regional anesthesia, patients associate with major operations — isn’t about putting patients to sleep during a procedure, Otuwa says. Regional anesthesia does not require patients to be unconscious during the procedure. But for general anesthesia, it’s about “continuously resuscitating them” while they’re under. That’s because the cocktail of inhaled and intravenous drugs used to induce and maintain general anesthesia creates a state of “physiologic imbalance,” Otuwa says. The drugs — which will render the patient unconscious, control pain, induce amnesia and prevent movement — “knock out the breathing, knock out his blood pressure, knock out his (control of body) temperature, knock out everything the body does when you’re alive,” Otuwa says. “So, now, it’s our job to maintain that state when (the patient is) alive but not awake.”

Dr. Mitch Keamy, a veteran Las Vegas physician anesthesiologist, says he doesn’t even tell patients he’s putting them to sleep because “I’m not putting you to sleep. I am creating a drug-induced coma which is reversible.”

“When you sleep at night, if somebody comes to you with a scalpel, you’re going to wake up. When you’re asleep at night, if your wife puts an elbow where your eye is, you’re going to say ‘Ouch’” Keamy says. “These are not things that happen during anesthesia because anesthesia is not sleep.

“Do I make patients nervous by saying that? I hope so, because, otherwise, it’s not informed consent. But then you reassure them, give them honest informed consent about what you’re going to do, then you reassure them of your ability to safely guide them through this process.”

Then, while the anesthesiologist quite literally keeps the patient alive and as comfortable as possible — a responsibility Keamy describes as acting as “the custodian of (the patient’s) well-being” — the surgeon can focus on the procedure itself.

“I think the anesthesiologist is just as important as the surgical process itself,” Blum says. “It can be the perfect surgery, and if the anesthesia is not up to par, the outcome might not be as favorable.”

During the operation, Otuwa will monitor a dizzying array of vital signs — including heart rate, body temperature, respiration, cardiac activity, oxygen saturation in the blood and carbon dioxide exhaled — as well as the patient’s “depth of consciousness” through brain function monitors that, he says, “tell you how conscious or unconscious a patient is.”

Through it all, Otuwa will continually administer and re-administer drugs and perform measures aimed at keeping the patient comfortable and manage the potentially deadly effects and side-effects of those drugs.

Another taken-for-granted miracle of modern medicine: Despite all of this complex medical and pharmacological choreography, anesthesia is relatively — maybe surprisingly — safe. Dr. Daniel Cole, president of the American Society of Anesthesiologists, notes that a 2011 review of data put the risk of anesthesia-associated mortality among healthy patients at 0.4 deaths per 100,000 cases.

Then, Cole says, “if you’re a little sicker, it would be 27 per 100,000, and if you’re pretty sick, it would be 55 per 100,000.”

In contrast, according to the study, anesthesia-related mortality was reported at about 64 per 100,000 operations during the ’40s. Trends “got significantly better in the ’70s and ’80s” Cole says, and anesthesia-related deaths fell significantly “with some of the technology and when safety standards get implemented.”

At the same time, there are data indicating that, over the past decade or so, anesthesia-related death rates have been “creeping up,” Cole says. “Not a lot, but creeping up.”

That is “not particularly due to anesthesia per se but probably due to a couple of factors,” Cole adds. Most notably, he says, patients today are “coming around for surgery (who) are sicker and sicker.”

Among the common conditions associated with general anesthesia complications are hypertension, diabetes, heart disease, conditions that involve blood flow to the brain, kidney failure, lung disease and obesity, Cole says, “and it has to do not only with the intraoperative piece but also with postoperative complications.”

Another reason for the apparent upward creep may be that “we have been doing a lot more procedures and new procedures that would essentially have been unthinkable about a decade or two ago,” Cole says. Cole says his father recently was scheduled to undergo heart surgery at the age of 85, and “I don’t think we would have done that 20 or 30 years ago.” “So anesthesia inherently has not changed or gotten worse,” Cole says. “It’s just (that) more risks are taken on with patients and procedures.”

Otuwa credits anesthesia’s safety record to “advances made in monitoring patients and because of the agents — the new drugs — that have come out on the market that are more friendly to the body. “It is really very, very rare, indeed, to have an adverse event, because of the monitoring and because of the medications we have, not only (for) doing anesthesia but for resuscitating.”

Keamy recalls that when he began practicing anesthesiology 37 years ago, “monitoring technology was primitive, and drugs were primitive.” Just 30 years ago, “I had a simple blood pressure monitor and electrocardiogram and a stethoscope,” he says. “There were no oxygen-measuring devices available. There were no ventilation measuring devices available. The technology to do invasive monitoring was much less advanced. We were just starting to get ultrasound technology, which was pretty primitive.”

Yet, anesthesia remains an often taken-for-granted part of medical care — even, Otuwa jokes, among anesthesiologists’ own family members.

“It’s like my 11-year-old son. He asks me, ‘Putting people to sleep, that’s all you do? You went to school for 11 years just to put people to sleep?” Otuwa says, laughing.

In the operating room, Otuwa begins by giving his patient calming medications (medications for nausea or digestive upset also can be given preventatively, if necessary). Then, other inhaled and injected ingredients of the anesthetic cocktail will be administered progressively over time as Otuwa constantly gauges their effectiveness and watches for potential adverse reactions.

The last drug the patient will remember receiving is the one that causes unconsciousness. That’s called the induction drug, and that’s “when we ask you to count for like 10 seconds and out, and then we take control from there,” Otuwa says.

Literally.

The induction drug is “very potent,” Otuwa says. “It stops your breathing. It knocks your blood pressure down.”

“So we have to breathe for you” Otuwa says, via intubation — the placing of an artificial airway — and a mechanical ventilator. Then, throughout the operation, Otuwa will manage all of the body’s processes that the body normally would manage for itself, deal with any unanticipated changes to the patient’s physiological state that might arise and keep the patient’s vital signs within acceptable ranges.

The anesthesiologist’s job is to “focus on the whole patient, while the surgeon is focusing on … getting a good outcome,” Keamy says. “We’re supposed to be parked there behind our bank of monitors and managing the patient’s overall physiology, managing the tenor of the room, managing the surgeon a little bit. My job is to make the procedure as safe and as comfortable for the patient as possible.”

The operating room is silent as Otuwa, Blum and other surgical team members work. Otuwa stands at the head of the table, occasionally injecting medications into an intravenous line, peering at his monitors constantly and examining the condition of his patient. The atmosphere is calm and almost unsettling in its routineness.

The tenor might be noticeably different with a trauma case or an emergency surgery. It’s in such cases “where you have the highest incidence of awareness of anesthesia,” Otuwa says.

Anesthesia awareness, or intraoperative awareness — in which the patient reports being aware of what was going on during surgery — “is a concern with some patients, and it tends to occur in high-risk groups of patients,” Cole says.

“It can be someone with medical conditions that may cause your blood pressure to go down unsatisfactorily” or occur when a medical issue requires lighter anesthesia to maintain the patient’s safety, Cole says. Intraoperative awareness also is more common in patients who have experienced it previously or whose family members have experienced it, “or if you drink a lot of alcohol or take a lot of other medications … related to the anesthetic, such as pain medications.”

The sounds escaping from the room’s monitors — beeps, drones, occasional higher-pitched trills — provide the operation’s musical score, whose individual notes are discernible only to Otuwa. And when the patient finally does awaken, Otuwa’s role, as vital as it has been, may be one that the patient acknowledges only briefly.

At least until that bill arrives? Otuwa laughs.

“When you get a bill, life is good,” he says, smiling. “You did very, very well to get a bill. Be happy.”

Your surgeon will generally advise you on how long before your procedure you should not eat and drink, what drugs to take and not to take, and the likely duration of your stay in hospital.

FASTING TIMES:

For adults, anaesethetists are unlikely to anaesthetise a patient unless they have been fasted for at least six hours prior to the procedure, although there are exceptions for emergency surgery. Water is usually allowed up to 2 hours prior to the procedure. However, these fasting times are only general guides, and your specific fasting time will be provided to your for your procedure.

DRUGS:

Most tablets are usually continued up to the day of surgery, but there are exceptions for tablets that can thin the blood, such as aspirin, warfarin, and novel anticoagulants. Your surgeon will provide instructions for your specific situation. Usually, depending on the procedure, Dr Wells may get you to skip your tablets (but not your insulin) for diabetes for the morning of the procedure. Those on insulin for an afternoon session usually have half their usual dose with an early breakfast, and skip their insulin altogether if there is a morning list. However, these are general guidelines, and you should seek specific instructions from your surgeon or Dr Wells for your procedure.