Dr Tryphena Ramesh
MBBS, MD, DNB (Anaes), Anaesthesiologist, CIHSR, Dimapur
In the beginning God made Adam. And right after that He delivered the first documented anaesthesia to Adam in order to create Eve from his rib. Genesis 2:21 reads “ And the Lord God caused a deep sleep to come upon him; and while he was sleeping,he took one of the man’s ribs and then closed up the place with flesh.” .It was literally the first branch of medicine that God used but it was one of the slowest to develop thereafter. By the 1800s Medicine had made great strides but the progress of Surgery was hampered by the lack of suitable and safe anaesthetic practices. There were conditions such as tumours, limb injuries, even complicated childbirth that required operations but often the patient had to make do with a draught of alcohol or a puff of opium to try to numb the intense pain that accompanied these procedures. Many feared the pain of the operation and chose to succumb to their illness. Eventually ether and chloroform were discovered but still complications often occurred.
With progress in Anaesthesia, new drugs have been made available that are able to make a patient entirely unconscious or make numb the area of the body being operated, while preserving consciousness. Safety in Anaesthesia has improved much over the years and this has enabled surgery to make great strides as well. It is now possible to operate on even those in the extremes of age- newborn babies and nonagerians. Fetal surgery (operation on the unborn baby in the womb) is now being performed for certain abnormal conditions detected during pregnancy, under appropriate anaesthesia.
Despite the advances made, due to the fact that Anaesthesia is given in the confines of the Operation theatre, many misconceptions exist among the public. The aim of Anaesthesia is to ensure that the patient has a safe, pain-free operation and can resume normal activities as soon as possible. There are many myths shrouding the practice of Anaesthesia. I have tried to address a few of them by answering some of the most frequent questions I have been asked about Anaesthesia.
1. I am terrified that I might feel pain during the operation. Will I be completely pain-free during the surgery?
If either you or someone you know has had to undergo an operation, the first thing that probably crossed your mind was whether you will be aware of the pain during of the operation. Let me assure you that we now have a range of drugs and equipment to ensure that you will be pain-free throughout the surgery. You can be guaranteed that you will have no pain right from when the surgeon cuts through your skin. However after the completion of the operation, once the effect of the anaesthetic drugs wear off, you will have some pain or discomfort depending on the extent of the operation you underwent. Thereafter you will be given oral or injectable medications to control the postoperative pain.
2. Do I have to be made unconscious for me to be pain-free during the operation?
Not necessarily. As a general rule of thumb, most procedures that require cutting the skin below the level of the umbilicus(belly-button) can be carried out under spinal anaesthesia. This means after a small injection that is given through your back into the fluid surrounding your main spinal nerves, you will temporarily lose sensation below your umbilicus but you will remain awake and alert. The operation will begin only after testing and ensuring that your lower half of the body is temporarily numb. You will not feel any pain. You will also find that you are not able to move your legs because they are temporarily numb. You will be able to move your legs normally and feel sensations normally after 3-4 hours since the effect of the drugs injected is only temporary. This means that this technique is usually used for procedures that are expected to last less than 3-4 hours. Your consciousness and breathing are not affected in this form of anaesthesia. However, it is best to discuss the options with your anaesthesiologist during the preanaesthetic check up. Depending on your medical fitness and the surgery planned, the anaesthesiologist will be able to tailor an anaesthetic plan that will be safest for you.
3. If I am going to remain conscious following spinal anaesthesia, will I be able to see the operation? I am scared of seeing the blood.
No! After the procedure of spinal anaesthesia is complete, an opaque cloth screen is usually placed between the area being operated and the patient’s face. This way the patient does not have to see the bleeding that might accompany the operation.
4.I was told that I will need General anaesthesia for my operation.If I am going to be unconscious because of General Anaesthesia during my operation, how long will I take to wake up after the operation is over? What if I don’t regain my consciousness!!!
The newer Anaesthetic agents like Isoflurane and Sevoflurane, that are available to us now in CIHSR,Dimapur, are safe and reversible. These are given to the patient in the form of anaestheticvapour (gas) which is breathed in through a tube inserted into the patient’s windpipe (endotracheal tube) after the patient is made unconscious. Most patients wake up within 10-15 minutes of discontinuing the delivery of the Anaesthetic agent. They may remain drowsy for a few hours afterwards and continue to sleep but they can be easily aroused. The process of making the patient unconscious and waking them up after the operation is controlled by the Anaesthesiologist and is mostly predictable. The newer Anaesthesia machines and the availability of newer monitoring equipment have ensured that it is safe for patients to be made unconscious in a controlled manner and more importantly they can be safely returned to a conscious state.
5.I was told by the nurse to remain fasting on the morning of the surgery. But if I don’t eat anything, how will my body have energy to withstand the surgery?
The food pipe (esophagus) and the windpipe (trachea) are placed very close to each other. Normally the protective reflexes we have when we are conscious prevent the food we have swallowed from going into the windpipe. The stomach secretes acid when food enters it, to aid in digestion and this acid can erode and damage the lungs if it were to enter the windpipe. This condition known as aspiration, can affect the ability of the lung to absorb Oxygen and endanger the patient’s life.
When a patient is made unconscious because of Anaesthesia, the protective reflexes in our body are lost and aspiration can occur if there are acidic food contents in the stomach. When we are kept fasting for short periods ( like the morning of the operation), the stomach remains empty and without food, less acid is produced. Therefore it is in the interest of the patient’s safety that the fasting is advised. Our human body has plenty of storedenergy and there willbe enough energy for the surgery even after a morning of no food intake.
6. I was told that for my Caesarean section, I will be given spinal anaesthesia. I am scared because so many people have told me that they have backache after the injection was given in their back. Is it true? Can I have general anaesthesia instead?
Backache commonly occurs in the later stages of pregnancy. Due to the hormonal changes in pregnancy, the ligaments which bind our back bone (vertebral column) together, relax. This, in addition to the growing uterus changing the posture of the pregnant woman, can lead to backache. Since the structure of the back is complex and includes many muscles, bones, nerves, ligaments and joints, it is often difficult to pinpoint the exact reason for backache. Many scientific studies have been done to assess if backache is caused by the injection given for spinal anaesthesia. The latest findings are that there is no clear evidence to say that backache is caused by the injection given for spinal anaesthesia. Most of the patients who complain of backache after a spinal anaesthesia have had backache even before the procedure, which could be due to many other reasons. Having an injection in the back merely draws attention and the patient often attributes the back pain to the injection given.The needle used for giving spinal anaesthesia nowadays is very thin(size 25 gauge). If the procedure is done by a qualified Anaesthesiologist who is proficient at spinal anaesthesia, it is usually accomplished in a single attempt and is unlikely to be a cause for backache later on.
There are certain operations like the Caesarean section which are preferably done under spinal anaesthesia. In a pregnant woman, we try to avoid giving multiple drugs before the baby is delivered in order to reduce the effects of these drugs on the baby. To induce general anaesthesia, a combination of drugs need to be given into the bloodstream and these can cause side effects such as decreased breathing efforts or excessive sleepiness in the newborn. Pregnancy hormones can also cause significant weight gain andchange the facial and neck profile of the woman. This makes the placement of a tube in the windpipe (which is required to supply oxygen and anaestheticvapourto the unconscious patient during General Anaesthesia) more difficult when compared to a non-pregnant woman. Theseare some of the important reasons why the Anaesthesiologist is likely to encourage the pregnant woman to have the Caesarean section done under spinal anaesthesia ( if she is found to be medically fit for the same during the preanaesthetic check up).
7.Why am I being asked to visit the Pre-Anaesthetic clinic?
Your treating surgeon will ask you to meet the Anaesthesiologist in the Pre-Anaesthetic clinic once the decision to operate has been made. This is a vital visit since it enables the Anaesthesiologist to assess the medical fitness of the patient , go through blood investigations ,radiology reports like Xray, Ultrasound, CT scan and also read the ECG if indicated. It is thus advised to carry along all the hospital reports you may currently have, for the Anaesthesiologist to make a thorough assessment and discuss an appropriate plan for Anaesthesia, including any risks that may occur during the operation. This visit can be used to clear any doubts or worries you may have about the Anaesthesia you will receive during the operation.This visit can help you be calm and free from undue anxiety before the operation.