I can offer some free advice regarding surgical or anesthesia questions

[IrishGirl]

I neglected to say in my original post that I am a Nurse Anesthetist. I dont know a ton about
hemodialysis and know less about peritoneal dialysis. But I do work in surgery, I put folks to sleep
every day for procedures...( I also wake them up !!!) This includes general anesthesia, local with sedation, etc. So if anyone wants to pick my brain about the anesthesia aspect, going to sleep, waking up, the agents we use, etc. I am glad to help ! If you have questions about spinals, general anesthesia versus sedation and whats the difference, then I would be happy to help. I went to Anesthesia School at William Beaumont Hospital in Royal Oak Michigan....IrishGirl



TOPIC MOVED to appropriate Section - General Discussion - Bajanne, Moderator

[willieandwinnie]

Good to know IrishGirl. I'll remember that. 

[Bajanne]

Thank you so much for offering your knowledge and experience to us like that.  I am sure that we will take you up on that when needed.Thanks again!

[KT0930]

I have a general question I've wondered about for several years. I was taking a course several years ago in Neuropsychology, and we read an article about general anasthesia. I think I remember it stating that the way anasthesia works is not entirely understood. Is that true?

[flip]

I'm glad you're here IrishGirl. I have a question for you.
 
What's normal procedure for a fistula (wrist)?

When I had mine done, I was told to expect light to moderate sedation. I was really shocked when, just prior to surgery, three NA's came in and started checking my throat for tube size and placement. I was totally out for 3 hours and in terrible pain when I woke up in Recovery.

[IrishGirl]

KT: We understand a lot more then we used to. The breathing gas is taken up through the lungs and dispersed through your body tissues. When you reach a certain percentage in your brain, you fall into sleep and it goes through different "levels" so we can keep you light, deep, or somewhere in the middle. Some of the IV medications are distributed differently and they are easier to understand. We know exactly  how long they should last, and where the are metabolized, (ie kidneys or liver)  On a renal patient we use the agents that leave the body through the liver so we do not mess with the renal system. The breathing gas is still a bit of a mystery but we have newer ones that are easier to understand and now we have brain wave moniters to moniter the impulses and that helps as well. IrishGirl

[IrishGirl]

Flip:

Most of the time an AV Fistula is put in using Sedation. (A general anesthesia is where you use breathing gas and its a much deeper and longer lasting type. You can use a number of different types of airway's for it, and sometimes you do insert a breathing tube. )  Generally speaking, we do not normally use a "General" anesthesia for such a procedure.  We always evaluate the airway of every single patient because they will all get oxygen in some for or another...everyone does in the Operating Room. And you never know if you might have to revert to a breathing tube due to length of surgery, etc so we always look down everyone's throat. I do not know if you had the General or the Sedation.
3 Hours sounds like a long case, but it can take awhile to get vascular access. They must locate the vessels, isolate them, and then fit the shunt in, the blood must be thin enough to flow thru it with ease, etc.  If a procedure takes 3 hours, thats a reason to go from sedation to a general. We can only give a patient so much sedative and have them keep breathing on their own. At some point they become more deeply anesthesized and you will need to breathe for them with some sort of mouth apparatus and may have to turn on breathing gas. Also, with sedation cases, the surgeon must numb the area with a local . If the area of numbness is perfect, we dont have to use so much agent. If the local does not take well, or its spotty and there are areas not as "numb" then we must give more and more and more of the agent. Sometimes patients will be soundly sleeping and snoring and seem very deeply snoozing, but they still move ! The surgeon cannot be expected to to hit a moving target. Those times we revert to a general, put in a breathing tube and give gas, which WILL render the patient motionless. Its awful you woke up in pain. We like to give something prior to waking up the patient, for pain. Unfortunately not every person does this and each hospital does things their own way. If a patient gets "too much" pain medication towards the end, they will be slower waking up. It is really awful you were in such pain and also 3 hours sounds like a long time. Its entirely possible you had a very long case, and it was more complex then originally planned. Some people have dreadful blood vessels and some are easy and they just slip right in. Its also possible you only had a sedation case and you were not intubated, just lightly sleeping the entire 3 hours....and you had nothing on board when you awoke. Very unfortunate and I am very sorry you were in such pain. We really try our best to avoid that. One would hope the recovery nurses take over when we drop you off in the pacu and they give you pain meds pronto. Hope I have helped you understand some. IrishGirl

[IrishGirl]

Flip,
I am responding again to your question, It also just occurred to me that the AV Fistula's are more difficult in patients that have bad blood vessels, most commonly people who are diabetics, patients who use agents that constrict the vessels like caffeine and nicotine, and sometimes patients who are heavier in build. If you are any of these things, your "Easy sedation" Fistula case may turn into a lengthy drawn out general anesthesia case. I dont know why there were 3 people looking down your throat! Its common to have 1 or 2 look, Maybe an Anesthesiologist, a Nurse Anesthetist and a Student?  I dont know who the 3d party was ! Its a basic part of the anesthesia assessment, we never put anyone to sleep without looking into their throat. We must be sure we can administer oxygen, breathing gas and put in a breathing tube if necessary. IrishGirl
 
 
 
 

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[devon]

Fascinating topic! Thanks for sharing!

My story is that I woke up during a rhinoplasty.  I could hear the docs talking about the Anes's.. recent vacation and the operating doc said, "I will give him 3 more hits right here" and I felt three hammer blows against the base of my nose.  Then, thankfully, I fell back into unconsciousness. There wasn't any pain but it was a distubing moment.

I have since then told any anesthesiologist to please be careful and don't let me wake up.  I don't want to go through that again.

-Devon

[paddbear0000]

I remember when I had a vitrectomy done on one of my eyes. At some point during the surgery, I woke up enough to see the dark shapes of the cutting tool being used on my eye! Yikes! I couldn't feel it tho. Being high on gas, it was kind of a surreal experience tho.

I have a question. I'm working on getting a kidney/pancreas transplant and am freaked out about the length of the procedure and even more so about the breathing and NG tubes! First, does being put to sleep for so long have any side effects or possible complications? Also, what is the NG tube for? Does it also help with breathing? I had a BAD experience with one that involved a TON of blood. I am not looking forward to either tube. Please tell me they will knock you out before putting either one in!

[IrishGirl]

Devon,
Many surgeons prefer to do their rhinoplasty's with  a sedation and local, not a general. This means that
you were never really "asleep" super deeply...just lightly asleep, like at home in your bed at night.
The thinking is this: If the surgeon has appropriately numbed the area he is working on (much like a dentist does with teeth) then the anesthesia provider only needs to give "light" sleeping medication.
Not a lot of stuff for pain, and certainly not the big guns! (The big guns being the breathing gas) The breathing gas puts your BRAIN to sleep. Lets face it, with a toe surgery and a numb toe., who the heck really wants their brain asleep? Makes no sense !! So many famously heard people who say they "Woke up" during surgery really did wake up from a light sedation, not from a general anesthesia and the difference is the breathing gas. The surgeons sometimes dictate what type they prefer...but the anesthesia provider really gets the last say...we always try to go with what the surgeon prefers. Some surgeons do ALL their rhinoplasty's with gas...some would rather not. As you said,  you "Woke up" but you did not feel any pain. This is a perfect example. Your surgeon had you perfectly numb !! However, you really wanted to not wake up at all during the surgery, as you said it was a disturbing moment for you. People have to let the anesthesia provider know they do NOT want to wake up at all, or hear or see anything the entire time. You are right though, we do use hammers and chisels !!! Other patients request to watch the entire surgery on the TV scope as long as they are numb., everyone has a different request and a different outlook. Some patients think its "cool" to watch their numb extremity
undergo surgery...and we are fine with that at our place too....as long as the surgeon is okay with it ! IrishGirl

[paddbear0000]

After reading your reply to Devon, I must add that my surgeon who did the vitrectomy, told me I would be under general anesthesia.

[IrishGirl]

Paddbear0000,
A renal and pancreas transplant will be a fairly long case. You will be stiff and sore from being in one position for a long time. Most the time, the longer you are asleep and under anesthesia only has a few
minor effects like that. The longer you are asleep on the table with breathing gas, the more hours, things like postoperative nausea and vomiting can happen. We all well know that throwing up is miserable especially if you have an abdominal incision so we try to avoid it at all costs. First off, you will be put totally and completely to sleep. You will be OUT OUT with breathing gas. After you are out they will first insert the breathing tube. There are 2 openings in the back of your throat. The front opening is your esophagus or stomach pipe. The one behind it is the breathing pipe. We first insert the breathing tube into the breathing pipe.  Its easy and not a big deal and the tube is about the size of the patients little finger. (We have different sizes so you will get an appropriate size) This is how we give the breathing gas. Next, we would insert the stomach tube and yes it IS necessary. It will go down into your stomach. We hook it to a suction cannister and it will keep the stomach empty all through the surgery. You will not be able to swallow air, secretions, saliva, whatever.....the stomach will remain nice and flat and out of the way of the surgeon. Think of a balloon UN-inflated as opposed to a big blown up balloon !!! You want the gastric tube so you wont retch or throw up, and so the surgeon does not have the stomach in his way. They will give you anti nausea medicine through your IV as well while your sleeping ! So, no the gastric/stomach tube does not help with the breathing but it has a different function and a very necessary one. If you have food in your stomach during surgery or other stuff...and the surgery goes on for a long time, it must be kept empty. hHe reason is, that while you are asleep you could retch that contents up into your lungs. This would result in pneumonia of course. This is why we insist patients do not eat or drink before surgery. If you have your surgery done in a place where its a common procedure and you have an excellent surgeon that you trust and has a great track record you have nothing to worry about !! The anesthesia is very very safe...even for hours and hours if necessary. You may be groggier upon awakening and take longer to wake up and get the cobwebs out of your brain....but be assured the anesthesia is safer then ever and the agents we use are just amazing !!! Its come a long  long way !! Dont let one bad experience scare you away.

The Vitrectomy was done with a local and sedation. Your eye surgeon numbed you good ! And probably told you it would be a general because sometimes they think it will be and then the decision is made to just do sedation by the anesthesia team. Also, some surgeons have a hard time between the 2 distinctions because they run so close...a deep sedation can in fact become close to a general and some patients just get a few "whiffs" of gas....its hard for me to say. I dont know your situation or your surgeon of course. Maybe you had a General to start with and the anesthesia provider lightened you up early for whatever reason he had to. We constantly tailor and retailor the agents to your moniters, your body, the breathing, the blood pressure, the heart rate, etc. (Extremely shallow breathing, very low blood pressure, high heart rate, etc. we shut it back....) But the anesthesia  was supposed to keep you sedated...and that can be light sedation or deep sedation. Sounds to me like yours was light ! Its eerie  being aware of all that stuff isnt it? Fact of the matter is, we sometimes go more light for eye surgery's because the surgeons like them somewhat light just in case they want to communicate with the patient, (ie "look up, look down, close your eye, etc) That all depends on the amount of work they are doing and their personal preference.

[Bajanne]

Just signing in to say how much I appreciate your sharing with us.  Knowledge is Power, we always say here at IHD.  And you are adding to our knowledge and power Irish Girl.  Thanks so much!   

[kellyt]

Fascinating topic! Thanks for sharing!

My story is that I woke up during a rhinoplasty.  I could hear the docs talking about the Anes's.. recent vacation and the operating doc said, "I will give him 3 more hits right here" and I felt three hammer blows against the base of my nose.  Then, thankfully, I fell back into unconsciousness. There wasn't any pain but it was a distubing moment.

I have since then told any anesthesiologist to please be careful and don't let me wake up.  I don't want to go through that again.

-Devon

Devon, I was in a similar situation when I had my second AV fistula placed in late October.  I was given the same "margarita" as they called it, with my first AV fistula, however, during the 2nd surgery I was alert - or in and out.  Now, mind you the surgeon told my husband after my first surgery that I was "awake the entire time", I have no recollection of being in the OR at all!  Thank God!  But, like I was saying, during my 2nd surgery I was awake and I could feel him cutting on my arm, as well as the sutures.  I was looking at the anesthesiologist the entire time.  She sat just to my right.  She even gave me a Kleenex at one point.  I remember hearing music and the surgeon asking his assistant "Who sings this song?".  The assistant said "I don't know" and I answered with the name of the band.  The surgeon then asked me if I had any musical requests.       When I woke up in recovery the surgeon came in and said "When you take your wrapping off in a few days, don't be surprised at how big the incision is".  I already knew, even though my arm was totally numb due to a nerve block shot, that my incision was clear up to my underarm.  I know I wasn't under heavy anesthesia, but I'm terrified I might do this in a major surgery.  Again, I was alert and I could talk a little, but I couldn't bring myself to tell him I felt the knife or the sutures.  Really strange!!!!!!!!!!!

Also, at one point either the surgeon or the assistant said "This is a really big arm".  I remember being devastated.  That made me cry even more.  My arms are big.  It sucks!   

[IrishGirl]

kellyt,

I believe the reason the surgeon told your husband you were awake the entire time the first surgery was because you were. In a manner of speaking. We give a medication that is similar to Valium but it wears off quicker. It is a "hypnotic" and once you recieve it in your IV you forget everything. Its an amnestic. People frequently say "I was OUT The whole time!" And they remember nothing, it feels like a very deep, general anesthesia. But I Can tell you after 16 years of doing this, these patients frequently appear to be very awake. They may talk, keep their eyes open, and join discussions during surgery. Some of them leave surgery, go to recovery, get up, get dressed and ride home, walking, talking, and acting perfectly normal......and appear to be perfectly awake, alert and normal. ..... and tell their spouse the next day "I dont remember leaving the hospital, or riding home, or anything at all."  We have no way of knowing exactly where their lights come back on. Sometimes its dose related.  Sometimes it wears off during surgery but the person demeanor does not change so we have to rely on the vital signs, depth of breathing, etc. To the patient, they were "asleep" the whole time. Many times patients have 2 identical surgery's and we do the same exact thing and they react differently. Frequently the only real way around this is to verbalize very adamantly what you want. If a patient tells me "I do not want to see anything, hear anything, I want to be so deeply sedated that I am not hearing you talk, etc. Then I do deep sedation and make fairly sure they do not remember. These days, frequently a sedation case is JUST sedation unless you request otherwise. Sedation simply means we give you something to help you relax. You may well hear everything said, every song played, and remember the conversations. Some people prefer that to being totally out. It all depends upon the individual. I rarely ever hear anyone make a remark in any way about a patient in such a way as "This is a really big arm" but if you are lightly sedated you will certainly know what is said. There was obviously someone in the room who was rude and making unacceptable remarks. However, I would have piped up and said "And YOU have a really really BIG MOUTH too" That would have shut them up! But thats just me. I greet rudeness with rudeness and it works for me. I apologize for the rudeness of your OR Staff. Most are not like that. You rpost said you could feel him cutting your arm. But, our question is always to the patient, "yes, you CAN feel it, but does it hurt?"  Its like the dentist office. You will feel him working. You will feel hot liquid, cold liquids, rubbing, touching, pressure, pushing, pulling. BUT you should not feel pain. Some surgeons do an excellent job of numbing up the site. Others can't do it any better then a first grader. Its sad, but its true. Some make my job easy, some make it hard. Its very hard to promise a patient you will only give them sedation if the surgeon cannot get that spot numb. Now what? We must revert to a general anesthesia at that point. Many times what we do depends on what the surgeon does. But the patient should always tell us exactly what they want and we do our best to get there. You DO have a say. Its your body and its your procedure and we DO value your input.

[kitkatz]

I once gave the surgeon such a hard time during a graft reconstructions, he had the anesthetist knock me out.  He was pissed at me when I woke up because I guess I complained at him the entire time I was sedated. I don't remember any of it.

[mysty]

Hi Irish Girl.. first let me say hello and thank you for offering your knowledge to all of us here..

My questions is maybe odd. 
Each time I go under.. it takes longer to come out of the anesthesia..They say they stopped it so im just sleeping but you open your eyes look around and are dead weight.. cant call anyone.
So seeing I'm due for yet another surgery here soon.. I really am curious.. why its takes me so long to come out of it (then of course my stomach turns inside out-blah!)

[paddbear0000]

Thanks for the info IrishGirl! I have another question tho. The time I was talking about before, when they tried to put an NG tube down my nose, it bleed horribly. I mean, blood shooting across the ER department floor bad. It took over a half hour to stop and they gave up. If you're completely asleep, how would they deal with this? Have you ever had this happen in the OR? I know it's not a sedation question, but I thought you might have an answer since you work in the OR. Thanks!

[jbeany]

Devon, I was in a similar situation when I had my second AV fistula placed in late October.  I was given the same "margarita" as they called it, with my first AV fistula, however, during the 2nd surgery I was alert - or in and out.  Now, mind you the surgeon told my husband after my first surgery that I was "awake the entire time", I have no recollection of being in the OR at all!  Thank God!  But, like I was saying, during my 2nd surgery I was awake and I could feel him cutting on my arm, as well as the sutures.  I was looking at the anesthesiologist the entire time.  She sat just to my right.  She even gave me a Kleenex at one point.  I remember hearing music and the surgeon asking his assistant "Who sings this song?".  The assistant said "I don't know" and I answered with the name of the band.  The surgeon then asked me if I had any musical requests.       When I woke up in recovery the surgeon came in and said "When you take your wrapping off in a few days, don't be surprised at how big the incision is".  I already knew, even though my arm was totally numb due to a nerve block shot, that my incision was clear up to my underarm.  I know I wasn't under heavy anesthesia, but I'm terrified I might do this in a major surgery.  Again, I was alert and I could talk a little, but I couldn't bring myself to tell him I felt the knife or the sutures.  Really strange!!!!!!!!!!!

Also, at one point either the surgeon or the assistant said "This is a really big arm".  I remember being devastated.  That made me cry even more.  My arms are big.  It sucks!   

I've had numerous sedations with Versed while they were ballooning my fistula.  I actually prefer not really being awake, so I simply tell them that, and they give me another dose if I'm still seeing and hearing things after the first dose.  Don't be afraid to tell them you are uncomfortable or that you would like to be deeper asleep!

[IrishGirl]

Mysty,

When you wake up, each time can be a bit different. But its important to remember that the
anesthesia is not an "event"  It is a "process'   You will wake up the same way you go to sleep and
its not like a light switch. Its like a series of steps....when you are waking up you must pass through them all.  You travel through stages..from a deep sleep to a regular type to a hypnotic type. That may be the one you are remembering. You are rather awake-ish and quite well aware of your surroundings...you mind is simply waking up before your body. Our body sometimes wakes up first. Those are patients who sometimes give us quite a battle.....they may be having a bad dream. Some patients we need combat pay for !!! They are asleep in their mind but their body is awake, moving, fighting struggling....sometimes the opposite may happen. Just relax and go with it and dont fight it. When you are awake in your mind just let your body lie there and give it time to wake up. When it does, and your tell it to move your hand, your hand will move. But there are areas of time where you wont be co-ordinated enough to make your mind or your body do what you want it to. Its normal and its brief. It usually depends on the length of surgery and the amount of anesthesia you had. The longer the surgical case, the more anesthesia, and the slower to wake up.

[IrishGirl]

paddbear00,
That sounds like a patients worst nightmare coming true. The NG tube goes down the nose and its very traumatic "Sometimes' Noses are very vascular. What an awful thing for you. Unfortunately noses can bleed when the tube is inserted and most especially if the patient is on blood thinners and if the patient is awake. In the OR we do it completely different. First, the patient is asleep. We put KY jelly on the tube and we frequently squirt a Neo-Synephrine type spray into the nostrils, both sides. THis will constrict the blood vessels inside the nose and keep it from bleeding. We wait a few minutes for it to vasoconstrictand then we insert the tube gently. If we meet resistance in one side of the nose, we take it out and attempt the other side. If we meet with difficulty we might try a smaller tube, they come in all sizes ! Its very easy to guide it into the stomach because the patient is asleep and there are muscle relaxants on board. The sphincters are nice and relaxed and we rarely if ever meet any resistance.  I have had 1 or 2 patients whose nose did bleed some during insertion and we apply pressure or ice if need be to stop the bleeding. It was minor. However, keep inmind in the operating room things are very controlled....as opposed to the ER which is well, ....not controlled. These are emergencies and they are icky, bloody, scary and messy. And yes, they are what nightmares are made of. After all these years and all I have seen, attempting to put a stomach tube into an awake patient still gives me the heebies and its one of the most traumatic and most brutal things I have ever seen.
Its horrible to put a person through it. Nosebleeds happen, and have to be dealt with. But sometimes we get a chance to "prepare" with our spray, etc and in the ER, things are done quickly and fast and
there is no "prep" time frequently. Swiftly is usually the way thing are done out of necessity. In the OR you dont see that type of thing very often.

[IrishGirl]

kitkatz,
Thats very common. Patients frequently forget every single thing that happened back in the OR
even though they were only sedated. However, sedated, hypnotized and sleeping patients can feel pain. We can tell by the heart rate, the blood pressure readings and the depth of the breathing. And sometimes they can move...so we know we need to do something. Even though you would never remember being in pain or being uncomfortable, that doesn't make it right. And it makes things more difficult for the surgeon too. We frequently start out with a light sedation or a deep sedation and move into a General Anesthesia with breathing gas. Sometimes its required to change. The surgeon must go deeper then he thought or do more work then he originally planned. He may have to get closer to a nerve he did not anticipate earlier. The patient may have difficulty lying still even though asleep. Dont worry about it, its pretty common .....so what if the surgeon was pissed. Thats not your fault. That is between the surgeon and anesthesia, certainly the patient is never to blame.

[paddbear0000]

Thank you, thank you, thank you! I feel better now. Not great, but a little better!   

[mysty]

Thank you so much Irish Girl.. I'll remember that.. just relax and let my body catch up.
I'm getting ready for surgery.. probably two more times..and it's always scarey to me..

Today I had that nasty ct scan and had to drink that nasty stuff..i got a very large stuck stone in my left kidney..
It's gotta go.. the pain just doubles me over..and I'm so not into letting pain do me in..
So glad you are here..
Your honesty .. straight forwardness and kindness in your replies.. is so refreshing..

I truly appreciate you..