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How to avoid general anesthesia

Updated on July 5, 2015

General anesthesia safety

Are you concerned about general anesthesia risks?

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Choose your anesthetic before your surgery

You are having a surgery. You are lying in the pre-op unit, separated from other patients by a thin curtain. Your anesthesiologist, whom you've probably never met before, walks in, introduces him- or herself, and begins a long, terrifying discussion of your anesthesia options. Not infrequently, he or she may strongly recommend a specific form of anesthesia , simply because the surgeon prefers it! There is no guarantee that he or she would even mention every option, either. Some patients assume general anesthesia is the only option for their surgery. Even if the anesthesiologist goes over every option, lying on a cart, with an IV line started, is not the best time and place to make such important decisions. As a patient, you have the right to be properly informed before you walk into the hospital, so you can give a truly informed consent. Your surgeon will usually leave the decision to the anesthesiologist, so it is not a good idea to rely on him or her to educate you, either. This hub, written by a former medical interpreter with a public health background, discusses alternatives to general anesthesia, their advantages and disadvantages, who can and cannot have them, and for which procedures.


Common surgeries and anesthesia options

(click column header to sort results)
Surgery  
Anesthesia options  
   
Appendectomy
General or spinal (http://www.nlm.nih.gov/medlineplus/ency/article/002921.htm)
 
D&C
General, spinal, epidural, local and/or IV sedation (http://www.medicinenet.com/script/main/mobileart.asp?articlekey=17350&page=3)
 
Hysterectomy
General, spinal, or epidural (http://my.clevelandclinic.org/services/hysterectomy/hic_what_you_need_to_know_about_hysterectomy.aspx)
 
Knee replacement
General, spinal, or epidural (http://www.webmd.com/a-to-z-guides/knee-replacement-surgery)
 
Prostatectomy
General, epidural (http://www.ucsfhealth.org/treatments/radical_prostatectomy/)
 
Hernia repair (open)
General, spinal, or local (http://www.webmd.com/a-to-z-guides/open-inguinal-hernia-repair-herniorrhaphy-hernioplasty)
 
Tubal ligation
General, spinal, local, and/or IV sedation (http://www.nlm.nih.gov/medlineplus/ency/article/002913.htm)
 

General anesthesia photo

General anesthesia facts

  • General anesthesia was first used for surgery in 1842 (http://www.histansoc.org.uk/timeline.html
  • Early general anesthetic agents were inhaled gases (ether and chloroform) (http://www.history.com/topics/ether-and-chloroform)
  • Gases are still used for anesthesia, administered through a tube inserted into the trachea (endotracheal anesthesia) after the patient is rendered unconscious with an IV medication (usually propofol).
  • Some surgeries commonly performed under general anesthesia can, in fact, be done under regional anesthesia ( spinal or epidural) or IV sedation, or a combination (e.g. spinal anesthesia plus IV sedation).

Advantages and Disadvantages of General Anesthesia

(click column header to sort results)
Advantages  
Disadvantages  
Versatile (any surgery site, any duration)
Not suitable for patients who do not wish to "go under"
Quick and easy to induce
More side effects
Suitable for patients unwilling to stay awake for the procedure
Can affect memory in elderly patients
Superior airway, breathing, and circulation control
Costlier than other forms of anesthesia
Suitable for patients who cannot have a spinal/epidural due to back problems or prior back surgery
Risk of anesthesia awareness
Suitable for patients with high intracranial pressure
Drowsiness afterwards
Sources: 1).http://emedicine.medscape.com/article/1271543-overview 2).http://www.healthline.com/health/pregnancy/pain-general-anesthesia#Overview1

Spinal anesthesia

Spinal anesthesia anatomy
Spinal anesthesia anatomy | Source

Spinal anesthesia facts

  • "Inadvertently administered" by Dr. James Corning (USA) in 1885 (http://www.grandroundsjournal.com/articles/gr09l001).
  • First used for surgery by Dr. August Bier (Germany) in 1898 ( ibid).
  • Best used for most surgeries below the navel (http://web.squ.edu.om/med-lib/med_cd/e_cds/health%20development/html/clients/WAWFSA/html/u12/u1208_01.htm)

Advantages and Disadvantages of Spinal Anesthesia

(click column header to sort results)
Advantages  
Disadvantages  
Cheaper to store and transport
Not suitable for surgeries lasting more than 2 hours
Superior postoperative pain relief
May cause blood pressure to drop
Less likely to cause respiratory problems/May be more suitable for asthmatic patients
May fail, requiring additional anesthetic
Fewer side effects (such as nausea and vomiting)
May be difficult/impossible to perform in some patients
No loss of consciousness
Not all patients should/ wish to be awake for the surgery
Sources: 1).http://web.squ.edu.om/med-lib/med_cd/e_cds/health%20development/html/clients/WAWFSA/html/u12/u1208_01.htm 2).http://www.patient.co.uk/health/your-spinal-anaesthetic#nav-4 3).http://www.northeasternanesthesia.com/youranasthesia/centra

Epidural anesthesia facts

  • First use: probably by Dr. James Corning in 1885 (http://www.nysora.com/techniques/neuraxial-and-perineuraxial-techniques/landmark-based/3423-spinal-anesthesia.html)
  • First use in humans to treat seminal incontinence (http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v01/010012r00.HTM).
  • Also used in pelvic and leg surgeries

Advantages and Disadvantages of Epidural Anesthesia

(click column header to sort results)
Advantages  
Disadvantages  
No loss of consciousness
Not all patients should/ wish to be awake for the surgery
Lower likelihood of side effects (nausea, vomiting)
Not suitable for patients with blood clotting disorders
Quicker recovery than from general anesthesia
Not suitable for patients with nervous system or lower back problems
Suitable for longer procedures
Longer and more difficult to induce
May be more suitable for asthmatic patients
May cause the blood pressure to drop
Sources: 1).http://global.ihi.com/alarm+service/health+fact+sheets/epidurals+for+surgery+and+pain+relief.aspx 2).http://www.northeasternanesthesia.com/youranasthesia/central.php

Advantages and Disadvantages of IV sedation

(click column header to sort results)
Advantages  
Disadvantages  
   
Good for minor surgeries and minimally invasive procedures
Not suitable for major surgeries
 
Quicker recovery than that from other forms of anesthesia
Airway not secure, requiring closer monitoring
 
Fewer side effects than general anesthesia
Requires fasting
 
Patient controls his/her own breathing
Impaired consciousness (scary for some patients)
 
Suitable for patients who do not wish to go under, but undergoing painful/invasive procedures
 
 
Provides anxiety control for procedures that do not require anesthesia (e.g MRI for claustrophobic patients or small children)
 
 

Do I really need general anesthesia?

The answer to that question depends, first and foremost, on the procedure you are having. "Certain types of procedures, such as laparoscopic surgery or neurosurgery, require general anesthesia, while others, such as knee arthroscopy, can be done via several different techniques"(http://www.berkshirehealthsystems.org/anesthesiafaqs).Before heading to the hospital, research anesthesia options for your particular surgery. Do not rely on your anesthesiologist to educate you, because he or she might push you to accept a certain form of anesthesia. The author had to fight her anesthesiologist to avoid general anesthesia for a procedure that did not even involve any incisions, simply because general anesthesia secures the airway better than deep sedation ( translation: the anesthesiologist has to monitor the patient more carefully under deep sedation than under general anesthesia and who wants to do extra work, right?). The author stood her ground and got deep sedation, and did well.

Researching your options shows you not only how to stand up for your preferences, but also when to step back and allow the doctors to do their job. Even if the surgery you are having can be performed under a spinal block, that does not mean everyone is a candidate for it. This is discussed in greater detail below.

Who cannot or should not receive spinal anesthesia?

Contraindications to spinal anesthesia can be divided into two categories: absolute and relative. Absolute containdications mean the patient is definitely not a candidate for a spinal block, while relative contraindications mean that a patient may still be able to receive spinal anesthesia, but certain difficulties exist or may arise, and need to be addressed.

You are absolutely not a candidate for spinal anesthesia if you have infection at the injection site, a bleeding disorder (coagulopathy), increased intracranial pressure, low blood volume (hypovolemia), or certain neurological disorders. It also goes without saying that you would never be given spinal anesthesia against your will (http://www.nysora.com/techniques/neuraxial-and-perineuraxial-techniques/landmark-based/3423-spinal-anesthesia.html). Relative contraindications to spinal anesthesia include septicemia, other neurological disorders, and anatomical back issues, including difficulty locating the dural space (http://web.squ.edu.om/med-lib/med_cd/e_cds/health%20development/html/clients/WAWFSA/html/u12/u1208_01.htm#coni). As a medical interpreter, I once witnessed an anesthesiologist refusing to administer spinal anesthesia to a patient patient who experienced occasional numbness in the legs (peripheral neuropathy), opting for general anesthesia instead.

Stages of Sedation

Source

Who should not have general anesthesia?

There are no absolute contradictions to general anesthesia( http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&type=bookPage&decorator=none&eid=4-u1.0-B978-1-4160-5898-4..00027-6--s0030&isbn=978-1-4160-5898-4). In other words, if you require a surgery that can only be performed under general anesthesia, then you are going to receive general anesthesia, regardless of your risk factors, preferences, health conditions, etc. That said, there are relative contraindications to general anesthesia, meaning patients who have these may either be given an alternate form of anesthesia (such as spinal block), or an alternative general anesthetic, or have these contraindications addressed prior to surgery. For example, "Patients with a history of malignant hyperthermia require avoidance of triggering agents and total intravenous anesthesia. " (ibid) Another example of a relative contraindication to general anesthesia is eating or drinking less than 6-8 hours prior to surgery. Patients undergoing planned surgeries are instructed not to eat or drink (known as NPO, or nihil per os, the Latin for "nothing by mouth") after a certain hour, usually midnight for mornimg surgeries (http://lanermc.org/Images/Interior/surgery%20safety%20brochure3.pdf) . Women in active labor are usually not allowed to eat (though sipping water may be allowed, depending on the hospital), just in case they opt for an epidural or require a Cesarean. With emergency surgeries, of course, this is not always possible, and waiting is not always an option, either. In those cases, the anesthesiologist may opt for a spinal block if the type and the duration of surgery, as well as the patient's condition, permit it, or proceed with general anesthesia if the spinal one cannot be performed, taking precautions such as applying cricoid pressure (http://www.steinergraphics.com/surgical/005_13.7.html).

Is sedation the right choice for Me?

That depends primarily on the procedure being performed and your health. Sedation is performed for minor surgeries (such as foot surgery, plastic surgery, or bone repair) and noninvasive or minimally invasive diagnostic procedures, such as colonoscopy (http://m.medlineplus.gov/ency/article/007409.htm).For some procedures, sedation is only administered to certain categories of patients, such as children and claustrophobic adults for MRIs (http://www.pedsanesthesia.org/patiented/sedation.iphtml).

Not everyone is a candidate for sedation, including diabetics, pregnant women, individuals with liver, kidney, and thyroid conditions, as well as patients on certain antidepressants and antianxiety medications (http://www.nashvillefirstimpressions.net/blog/post/contraindications-for-sedation.html).

Is anesthesia overused?

In the author's opinion, anesthesia is definitely overused in the United States. Take colonoscopies, for instance. While they are routinely performed under sedation in the United States, this is less common in Finland and Norway, for example ( http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3329613/).

Someone might ask: "What's the big deal? What's wrong with people being comfortable, if that's what they prefer? Why suffer?". The author does not wish suffering on anyone. Patients are most certainly entitled to their comfort, but they are just as entitled to know all the options available to them, all the potential side effects, and the fact that some procedures can be performed with other, safer anesthetics/sedatives, or none at all. Some patients prefer not to be sedated for a colonoscopy, due to the side effects, for example, but may not even know that unsedated colonoscopy is an option. Do they not have the right to request such an option, or do doctors have the right to patronize patients and assume they know what is in their patients' best interest? The author does not believe doctors have the right to force their opinions on conscious, sane patients. No one should automatically be sedated just because that's how most patients prefer it.

For further reading

1). http://www.mayoclinic.org/tests-procedures/anesthesia/basics/definition/prc-20014786

2). http://www.aana.com/forpatients/Pages/Anesthetic-Awareness-Fact-Sheet.aspx

3).http://edition.cnn.com/2014/11/28/health/wake-up-during-surgery/

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