A guest column by the American Society of Anesthesiologists.
Not so many years ago, surgeons wouldn’t operate on patients they considered too old to tolerate the stress of anesthesia and surgery. Today, however, patients of every age — from Baby Boomers to the Greatest Generation — undergo anesthesia safely for surgery and diagnostic procedures.
Realistically, even if you believe that 60 is the new 40, concerns about having anesthesia are different for 60-year-olds and their parents than for 20-somethings. Here are answers to 10 frequently asked questions about anesthesia for those of us — myself included — who no longer need to worry about being asked for ID if we order a drink.
1. Who will be giving me anesthesia? It’s important to find out who will be in charge of your anesthesia care. In some hospitals, a physician anesthesiologist (a medical doctor who specializes in anesthesia) will be personally taking care of you. In others, a physician anesthesiologist may supervise anesthesiologist assistants, residents or nurse anesthetists on an Anesthesia Care Team. Sometimes a nurse anesthetist may work alone without physician oversight, though this is not permitted in many states. Ask your surgeon or call the hospital in advance to make sure a physician anesthesiologist will be on site.
2. What is the chance of a serious complication from anesthesia? Better medications and monitoring equipment have made anesthesia remarkably safe, which is why we can offer anesthesia today even to patients in their 90s. A better question to ask would be this: What is my chance of complications from the whole experience of anesthesia and surgery? The American College of Surgeons has developed an easy-to-use online calculator (www.riskcalculator.facs.org) that can predict your outcome risk depending on the type of surgery, your age and any medical problems you already have. The analysis estimates your chance of a heart attack, pneumonia, infection, and other problems that may occur after anesthesia and surgery.
3. Does a breathing tube have to be used during the operation? For most major operations under general anesthesia, a breathing tube is necessary. Usually, it is inserted into the trachea (windpipe) after the patient is unconscious and taken out at the end of surgery. In general anesthesia, you are unconscious and have no awareness of other sensations. For many minor procedures or diagnostic tests, sedation alone is enough and a breathing tube isn’t needed. Sedation is a semi-conscious state that allows you to be comfortable during surgical or medical procedures. There are three stages of sedation: minimal, moderate and deep. If you ever were told that it was difficult to insert a breathing tube during a previous operation, be sure to tell the physician anesthesiologist so that special airway equipment can be ready for you. This can happen, for example, as a result of rheumatoid arthritis or previous neck surgery.
4. Should blood pressure medicines be taken on the morning of surgery? Doctors may differ in their opinions on this question. As a general rule, I advise patients to take all blood pressure medications at the usual time on the day before surgery. But I prefer for my patients not to take any medications on the morning of surgery. Fluid pills such as hydrochlorothiazide may cause dehydration, and other blood pressure medications such as lisinopril (Zestril) or valsartan (Diovan) may contribute to dangerously low blood pressure under anesthesia. If a patient’s blood pressure is high on the day of surgery, we can use I.V. medications to bring it to a safe level.
5. Should all blood thinners be stopped a week before surgery? This is a complicated issue, and the answer depends on which blood thinner has been prescribed and why. If you have coronary artery stents, for example, you may be told to stop clopidogrel (Plavix) a week before surgery, but continue taking baby aspirin. If you are taking warfarin (Coumadin) for an irregular heartbeat or an artificial heart valve, you may be advised to stop taking it and switch to a shorter-acting blood thinner for a few days. Your surgeon and your cardiologist should agree on the best plan for your situation. Don’t just follow pre-printed instructions that the office staff may give you; talk to all your physicians in advance to be clear about the safest plan for you.
6. Should I bring a list of my medications with me, or can I assume that the hospital will have all the information? Unfortunately, communication between doctor’s offices and hospitals isn’t always perfect, and your medical records may not be complete when you arrive for surgery. It’s always a great idea to bring a list of your medications and doses, as well as a written summary of your medical conditions and previous operations you may have had.
7. Do I have to discuss how much I drink or smoke? If you’re uncomfortable discussing your current use of alcohol, tobacco, pain medications, marijuana, sedatives, or anything else while family members are present, just say goodbye to them and send them to the waiting area so that you can have a private conversation with your physician anesthesiologist and nurses. We aren’t judgmental, and we really do need to know. Routine use of alcohol, pain medications or sedatives can affect the amount of anesthesia you may need. Smoking damages the lungs –so please be honest with us about your current habits. You may safely keep to yourself how much of anything, legal or illegal, you smoked in your youth.
8. Do I need to mention cosmetic surgery? Again, if you don’t want family members or visitors to know, just ask them to say goodbye and wait outside. But please tell us. Eyelid surgery (blepharoplasty) may cause your eyes to close incompletely when you’re under anesthesia. If we know about it, we can take extra precautions to protect your eyes from dryness or corneal abrasion. Chin implants may conceal a difficult airway. Breast implants may be at risk of injury during lung surgery, and tummy tucks can affect wound healing after abdominal surgery. So please let your doctors and nurses know about all your operations.
9. Are older patients at risk for confusion after anesthesia? Older patients who already have signs of confusion or dementia are at risk for increasing confusion (also known as postoperative delirium) after anesthesia and surgery. Patients who have had a stroke or a mini-stroke (TIA) are also at higher risk. If this is a concern, speak with the physician anesthesiologist, who can explain more about anesthesia techniques and monitoring that will reduce the chance of problems. The physician anesthesiologist may recommend regional anesthesia (spinal, epidural or nerve block) if it is appropriate for the surgery.
10. Why is it important not to eat or drink anything after midnight? The answer to this question is the same for patients of any age. When a patient is unconscious or sedated, food or liquid in the stomach could come back up into the throat and get into the lungs, causing dangerous pneumonia. Solid foods and creamy liquids are the worst offenders. If your surgery is scheduled later in the afternoon, you may be permitted to have water or clear liquids up to six hours before the procedure.
If you have special concerns or risk factors for anesthesia, your surgeon or your hospital should be able to arrange for consultation with a physician anesthesiologist ahead of time. Otherwise, you will meet your physician anesthesiologist on the morning of surgery, and he or she will explain the anesthesia plan and answer any questions you and your family may have. Check your hospital’s website; many have information about the physician anesthesiologists who practice there.
For more information about anesthesia, please visit the American Society of Anesthesiologists website for patients and families.
Karen S. Sibert is an associate professor of anesthesiology, Cedars-Sinai Medical Center. She blogs at A Penned Point.