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Although the effects of sedation are better described in terms of “stages” or being part of a “continuum,” sedation is usually divided into three categories. The three levels of sedation are: With any of the three levels of sedation, you may receive an injection of local anesthetic to numb the surgical site. You may or may not feel some discomfort as this medication is injected, depending on how sedated you are.
1. Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. The patient feels relaxed and will be awake. 2. Moderate sedation/analgesia (conscious sedation) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Patients feel drowsy and may even sleep through much of the procedure. Patients may or may not remember being in the procedure room. 3. Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. Patients sleep through the procedure with little or no memory of the procedure room. Breathing is slow. With deep sedation, oxygen is normally given.
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Different Anesthesia Options Available A topical cream is applied to the treatment site in advance or an injection at the treatment site will numb only that area. A topical local anesthetic is intended to be applied directly to the area to be anesthetized, usually the mucous membranes of the skin. When a local anesthetic is applied directly to the mucous membranes or when it is injected around the nerve fibers, it produces a loss of sensation by inhibiting the nerve excitation or conduction.
Drugs used in local anesthetic topical preparations:
Topical anesthetics relieve pain and itching by deadening the nerve endings in the skin. They are ingredients in a variety of nonprescription products that are applied to the skin to relieve the discomfort of sunburn, insect bites, poison ivy, and minor cuts, scratches and burns. These preparations are also used to help deaden an area first before injections. Topical anesthetics come prepared as creams, ointments, lotions and gels. Topical anesthesia, in the form of lidocaine/prilocaine (EMLA Cream) is most commonly used to enable relatively painless injections (such as BOTOX or Dermal Fillers)
Drugs used in local anesthetic injections are usually:
Local anesthesia consists of the area of the body to be operated on is anesthetized with a mixture of Lidocaine (“Novocaine”) and epinephrine. Once everything is injected, the regions are entirely numb and the procedure can be performed painlessly. The epinephrine constricts blood vessels and therefore causes a lack of vessel-dilating anesthesia medications. Infiltration or injection into the surgical area with a needle is the most frequently used local anesthesia technique.
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DRUGS USED FOR LOCAL ANESTHESIA BY INJECTION
ADVANTAGES OF LOCAL ANESTHESIA
DISADVANTAGES OF LOCAL ANESTHESIA
LIDOCAINE TOXICITY Lidocaine toxicity is a rare complication that can occur when anesthetic levels become too high. Symptoms that can occur from Lidocaine Toxicity:
The most severe forms of local anesthetic toxicity results in a very low blood pressure in which the heart rate slows considerably and there could be an irregular heart rhythm.
DRUG INTERACTIONS WITH LIDOCAINE (LOCAL ANESTHESTIC) It is imperative that the patient needs to tell their surgeon what drugs they might be taking on a regular basis, as certain medication can interact with local anesthetics and increase the risk of toxicity. The surgeon as well needs to be informed about all new medications that the patient starts taking after the pre-op appointment and before surgery.
What to expect from Local Anesthesia: Topical cream might cause some skin irritation or dryness. Injectable anesthetic agents might cause localized swelling. Each local anesthetic will have a different rate of toxicity, absorption and duration of action.
Tumescent anesthesia is a common technique used for liposuction. A solution of Epinephrine, Lidocaine, and Saline is injected into the surgical area where the liposuction is going to be performed. Tumescent anesthesia with highly diluted lidocaine and epinephrine has transformed lipoplasty from a highly vascular surgery to a painless and virtually bloodless office-based procedure. The area after injection becomes swollen immediately which comes from the surrounding tissue absorbing the medication. How Tumescent Anesthesia Works:
ADVANTAGES OF TUMESCENT ANESTHESIA Several advantages of the tumescent anesthesia include the following:
DISADVANTAGES OF TUMESCENT ANESTHESIA The three risks of local anesthesia for tumescent liposuction are:
COMMON SIDE EFFECTS FROM TUMESCENT ANESTHESIA Common side effects of tumescent lidocaine that are not considered signs of toxicity include:
“Conscious Sedation” or complete sedation involves either a local anesthetic administered topically or by injection: A nerve block with injection or sedation drugs (such as Valium, Ativan, etc.) administered through an IV or orally.
If inserted by an IV – this is usually placed in the inside of the elbow or on the back of the hand. The needle goes in with an IV and once placed, it is withdrawn with a little catheter left behind to deliver the meds and saline solution to keep you hydrated during the procedure.
Twilight anesthesia is also known as:
Patients under twilight anesthesia are in a sedated state, but the patient may not be entirely asleep. The anesthesia relieves the anxiety which the patient might be exhibiting and also creates a state of amnesia so that the patient does not remember the procedure later on. Many of the drugs used in twilight anesthesia are the same drugs used for general; however the dosages are much lower. IV sedation is a good middle ground between local anesthesia (where the patient is awake) and general anesthesia (where the patient is completely unconscious). It is sometimes preferred to general anesthesia because patients recover more quickly with less nausea and vomiting. Twilight is different from general anesthesia, as the patient is still breathing spontaneously without a breathing tube inserted. Additional oxygen is delivered to the patient through the nose with small plastic tubing. The anesthetist follows the patient’s vital signs and delivers the medications through an IV. The patient’s vital signs and other bodily reactions are monitored with a blood pressure cuff, heart rate monitor, pulse oximeter (that measures the level of oxygen in the blood), and an EKG machine. This type of sedation is normally combined with injection of local anesthetic at the surgical site for additional pain control and to minimize bleeding. Most of these medications are very short-lived which requires a watchful and experienced anesthetist to ensure enough but not too much relaxing and narcotic medications. Once the medication drip is turned off, the patient regains full consciousness within a couple of minutes ensuring a smooth awakening without coughing and retching. Normally there is much less nausea with Conscious Sedation than general anesthesia. Twilight anesthesia requires an anesthesiologist experienced with conscious sedation, a skill usually mastered by specialists working in day-surgery centers.
“Conscious Sedation” or Twilight can be given by:
The anesthesiologist will customize the cocktail specifically for the patient’s needs. Most of the time, an anti-anxiety agent such as Valium or Ativan is given before the procedure to help with the patient’s anxiety. As with any type of anesthesia, the anesthesiologist will monitor you when receiving sedation analgesia. These monitors are very important to ensure your safety. They are used to monitor your heart rate and rhythm, blood pressure and the oxygen levels of your blood. During moderate and deep sedation, someone will be solely responsible for monitoring your vital signs and controlling your level of consciousness.
DRUGS USED IN IV SEDATION OR TWILIGHT The medication that is used with Twilight Anesthesia:
Versed is used often, as it tends to calm the patient before entering the operating room. Versed relaxes the patient and causes temporary amnesia, blocking memory of the first few minutes of the injection. Fentanyl is a strong narcotic pain medication in which it blocks pain receptor sites, lowers blood pressure and heart rate, and can help with counteracting normal responses to pain that occur during surgery. Some of the newer narcotic drugs used are Sufentanil, Remifentanil and Alfentanil, along with the older drugs like Morphine and Demerol. All of these drugs off long lasting narcotic pain relief that can be administered through the IV. Side effect of all narcotic pain medication is nausea and vomiting. Propofol which is also known as Diprivan is a popular medication that can induce moderate to heavy sedation without the problems of disorientation afterwards. Once the drugs are stopped in the IV, the patient will be awake within five minutes. Ketamine can be given with the local anesthetic is injected because it also makes the patient unaware of his surroundings. Side effects with Ketamine include heart rate disturbances and hallucinations. Some physicians are using a new anesthesia technique called PK – which is a combination of Propofol with Ketamine.
ADVANTAGES OF TWILIGHT ANESTHESIA Twilight anesthesia has some distinct advantages over general anesthesia:
Twilight anesthesia should always be performed by a certified anesthesiologist, who will interview the patient before the surgery and monitor the patient’s vital signs during the actual procedure. A local or regional anesthetic is always applied to the actual area having the procedure. This helps with the patient pain once they are fully awake after the surgery. The drugs used in twilight anesthesia are fast acting, and also quick to reverse, so the patient can be woken up in a matter of minutes.
DISADVANTAGES OF TWILIGHT ANESTHESIA As with any medical procedure, there are risks to twilight anesthesia.
What to expect from Twilight or Conscious Sedation: With some forums of sedation drugs you might feel nauseated and sleepy. You should not drive for a minimum of 24 hours after any form of sedation – nor should you be left without adult supervision.
This injection eliminates pain on a larger area of the body. It blocks a group of nerves so that the pain signal cannot reach the brain. An example of a regional anesthesia is an “epidural” used during childbirth, or a spinal. This type of anesthesia is used for many areas of cosmetic surgery; however breast augmentation is not one of the usages. A nerve block or regional block involves injecting the anesthetic medicine at the root of a particular nerve so that sensation is blocked along the branches of that nerve. Regional Blocks require much less anesthetic medication which lessens the possibility of toxicity occurring. There also tends to be a reduced blood loss compared to general anesthesia since the medication used lowers the blood pressure in the specific area that is being surgically worked on. Regional blocks help with pain control by blocking it completely or greatly reducing the episode. Regional anesthesia can block or reduce pain anywhere from several hours to several days, depending on the medication and the technique that is used. Some surgeons have been know to do a “nerve block” at the end of surgery to reduce pain for the first few days during recovery. Usually long or difficult surgeries are not candidates for Regional Blocks. With regional anesthesia it is injected around a large nerve or nerves. These nerves give sensation to the site of the procedure. Regional blocks are normally used in addition to a local anesthetic. Unlike local numbing, the medication is injected far away from the procedure site. Although regional blocks cause a larger area of the body to be numb than local anesthesia, the medication is the same. It takes a few minutes for the medication to have its full effect, and the person should not be able to feel pain in the area. Regional blocks also paralyze the muscles in the area. Sedative medications may be given before and during the procedure, usually through an intravenous line, or IV.
Copyright © 2010 ADAM, Inc. - Used with permission Location of the Spinal / Epidural
ADVANTAGES OF REGIONAL BLOCK ANESTHESIA
DISADVANTAGES OF REGIONAL BLOCK ANESTHESIA
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COMPLICATIONS OF REGIONAL BLOCK / EPIDURAL (SPINAL)
What to expect from Regional Anesthesia: A regional might cause the targeted area to be weakened, affecting normal movement until the anesthesia wears off. You may experience numbness, swelling and tingling in your extremities depending on the area targeted.
General anesthesia basically means that the surgical patient is completely asleep and not aware of his or her surroundings. The patient is given a drug that bring about a reversible state of consciousness so that one is unable to experience any pain. The anesthesia is administered via inhalation or by injection and can be used with or without controlled breathing through a tube in the throat, known as intubation. When the patient is intubated, a tube is placed in the windpipe (trachea) which is connected to a respirator machine.
All control of breathing function is taken over by the anesthesiologist who monitors the patient’s vital signs:
The experienced anesthesiologist uses all this data to decide which inhalation gases and intravenous (IV) medications to administer to the patient. If the surgery is going to be long in duration normally general anesthesia will be used, to make it easier on the patient. Each surgeon will have their own guidelines on what the protocol should be regarding patients and anesthesia. General anesthesia should only be given in an accredited or licensed facility in order to monitor the patient closely and assure safety.
All licensed or accredited facilities that allow general anesthesia should be equipped with a CRASH CART in case of an emergency situation and only administered by a licensed medical doctor whose specialty is an anesthesiologist or nurse anesthetist.
Photo image courtesy of Lifeline Image of a Crash Cart
There are four stages of general anesthesia:
The "Pre-Medication" Stage uses sedating medications, usually Versed, to calm and relax the patient before entering the operating room. The Second Stage - "Going Under" or induction stage has strong drugs that are given through an intravenous (IV) line to put the patient to sleep and control pain. Sometimes depending on the patient and their needs a face mask is used as well. After going under, the patient may be so sleepy that the tongue falls back in the mouth and blocks the airway.
To prevent the tongue from blocking the airway it must be protected and this can be accomplished in one of three ways:
The Third Stage is known as the "Maintenance Phase" - in which the patient is kept comfortable and vital signs are monitored. In some cases, the maintenance phase may last for several hours while the surgeon performs the surgical procedure. During this time inhaled anesthetics (medication in a gaseous form) can be administered with or without the help of a ventilator (breathing machine) The Fourth or “Coming Out” Stage is near the end of the surgical procedure. The anesthetic vapors are turned down and the patient slowly regains consciousness before being transferred to the recovery room.
ADVANTAGES OF GENERAL ANESTHESIA
DISADVANTAGES OF GENERAL ANESTHESIA
What to expect after receiving General Anesthesia: You will awake like you have been in a deep sleep. Your throat might be a little sore from the intubation of the tube down your throat. You might feel nauseated, but most anesthesiologists take the necessary steps to prevent this from happening by giving you a medication through the IV. Many patients believe that anesthesia causes dryness of the skin and also some hair loss. Staying well hydrated in the 48 hours following general anesthesia is very important, regardless of how you feel.
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Fortunately most "bad reactions" to anesthesia are not life-threatening. However, all forms of anesthesia including the different forms of local, can carry a risk of an allergic reaction. Anesthesia exposes the body to controlled levels of toxic chemicals in order to make sure there is no pain felt during a surgical procedure. The main goal of anesthesia is to either stop pain temporarily or to induce a semi-conscious or unconscious state. Even though anesthesia carries a risk, the benefits outweigh any potential disadvantage. The most important factor is making sure that whoever administers the anesthesia are board certified in anesthesiology. By doing this, you reduce the risks of any complication that might arise during surgery. All body functions and chemistry are monitored during your surgery to ensure a safe procedure. The most common reaction or danger of having anesthesia is an allergic reaction to one of the medications used. This is addressed immediately by the attending anesthesiologist by monitoring your vital signs. If an allergic reaction occurs, your anesthesiologist is equipped to handle this immediately. Severe allergic reactions during anesthesia are fortunately rare. It is very important to tell your anesthesiologist every medication you take on a regular basis, so that he can prevent any potential problem during surgery.
Malignant hyperthermia is a very rare complication from general anesthesia, which can sometimes be fatal. The inhaled agents used in the anesthesia can sometimes cause a biochemical reaction which is marked by intense muscle contractions that will eventually lead to rigidity in muscle tissue. Hyperthermia is another word for an abnormal high fever and muscle breakdown. How Malignant Hyperthermia Happens:
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