About anaesthesia The word anaesthesia is coined from two Greek words: "an" meaning "without" and "aesthesis" meaning "sensation". There are various types of anaesthesia. Throughout their lives, most people will undergo anaesthesia either during the birth of their baby or for a surgical procedure. These procedures may be relatively simple surgery on a day-stay basis or major surgery requiring complex team work to provide the best possible outcome for every patient. Many of today’s operations are made possible as a result of developments in anaesthesia and the training of specialist anaesthetists. Patients having surgery will have involvement from the anaesthetic team from the preoperative assessment of their medical conditions and planning of their medical care, to closely monitoring their health and wellbeing throughout their procedure to ensure a smooth and comfortable recovery. Relief of pain and suffering is central to the practice of anaesthesia. Despite an increase in the complexity of surgical operations, modern anaesthesia is relatively safe due to high standards of training that emphasise quality and safety. In addition, there have been improvements in drugs and equipment. Increased support for research to improve anaesthesia has resulted in Australia and New Zealand having one of the best patient safety records in the world. What is anaesthesia? Anaesthesia refers to the practice of administering medications either by injection or by inhalation (breathing in) that produce a state of unconsciousness that eliminates all sensations including the feeling of pain (analgesia) and other unpleasant sensations, which allows medical and surgical procedures to be undertaken without causing undue distress or discomfort. Types of anaesthetic given Procedural sedation Procedural sedation is used for procedures where general anaesthesia is not required and allows patients to tolerate procedures that would otherwise be uncomfortable or painful. It may be associated with a lack of memory of any distressing events. Conscious sedation Conscious sedation is defined as a medication-induced state that reduces the patient’s level of consciousness during which the patient can respond purposefully to verbal commands or light stimulation by touch. Analgesia Analgesia is the reduction or elimination of the patient experiencing pain by medications that act locally, such as local anaesthetics (which interfere with nerve conduction) or generally, such as opioid medications (which decrease the patient’s experience of pain in the central nervous system). Regional anaesthesia Regional anaesthesia is an umbrella term used to describe numbing anaesthesia using nerve blocks, epidural blocks pain relief and having a baby and spinal blocks. Regional anaesthesia involves the injection of local anaesthetic in the vicinity of major nerve bundles supplying body areas, such as the thigh, ankle, forearm, hand or shoulder. Regional anaesthesia is sometimes achieved by using a nerve-locating device, such as a nerve stimulator, or by using ultrasound, which is a painless procedure used to demonstrate internal body structures using sound waves to create an image. These devices help to locate the selected nerve(s) so that local anaesthetics can be delivered with improved accuracy. Regional anaesthesia may be used on its own or combined with general anaesthesia. Once local anaesthetic is injected in the desired region, patients may experience numbness and tingling in the area supplied by the nerves and it may become difficult or impossible to move that part of the body. General anaesthesia General anaesthesia produces a drug-induced state where the patient will not respond to any stimuli, including pain. It may be associated with changes in breathing and circulation. What is an anaesthetist? Specialist anaesthetists are fully qualified medical doctors who hold a degree in medicine and spend at least two years working in the hospital system before completing a further five years (or equivalent) of accredited training in anaesthesia, culminating in being awarded a diploma of fellowship of the Australian and New Zealand College of Anaesthetists (ANZCA), which can be recognised by the initials FANZCA after their name. The ANZCA training program includes at least two years of general medical education and training followed by five years of approved specialist training. This includes multiple assessments, both at the hospitals where trainees work and by formal examinations. When trainees are in the training program they are called registrars. After completing the five-year training program, successful registrars can become Fellows of the College and can practise as anaesthetists in Australia and New Zealand. Anaesthetists provide a wide range of medical services and are part of multidisciplinary teams providing health care to patients. Anaesthetists have a direct role in assessing patients before operations. They play an important and primary role in caring for the patient before, during and after surgery. They are trained in all forms of anaesthesia. Anaesthetists play a pivotal role in resuscitating acutely unwell patients, including trauma victims, and assist with the management of patients suffering from acute or chronic pain, as well as providing pain relief for women in labour. Clinical anaesthesia is built on the knowledge of physiology (how the body works) and pharmacology (how medications work in the body). A thorough understanding is required about the ways in which the body responds to anaesthesia and surgery, and how these physiological responses are affected and altered by the patient’s health. Anaesthetists must have an extensive knowledge of medicine and surgery as an understanding of the basic sciences. How does your anaesthetist stay up to date? After they obtain their fellowship, anaesthetists continue to update their skills by regularly attending professional sessions. It is mandatory for anaesthetists to participate in a continuing professional development program in order for them to continue to practise. Each year ANZCA runs a series of scientific meetings attended by leading local and international experts, and where new techniques and technology can be presented along with research findings. There are also extensive workshop programs. ANZCA’s Education Development unit provides a range of services to ensure that ANZCA and its fellows remain at the forefront of innovation and best practice in anaesthesia and pain medicine. Click this link to be redirected to the ANZCA website: http://www.anzca.edu.au/patients/what-is-anaesthesia

This information is only a guide and should not replace information supplied by your anaesthetist. If you have any questions about your anaesthetic, please speak with your treating specialist. Anaesthesia options Different types of anaesthesia may be used individually or in combination as appropriate. For some types of surgery, several options are available to facilitate surgical conditions and to provide pain relief. A specialist anaesthetist will consult with the patient and the surgeon to offer the safest and most appropriate type of anaesthesia for the clinical situation. Local anaesthesia Local anaesthesia involves the injection of local anaesthetic into the tissues near the surgical site. It may be used alone or in combination with sedation or general anaesthesia after consideration of the extent and duration of the surgery and patient requests. It is usually used for minor surgery, such as toenail repair, skin lesion or a cut to remove something. It may not be appropriate if infection is present. Regional anaesthesia Regional anaesthesia involves the injection of local anaesthetic around major nerve bundles supplying body areas, such as the thigh, ankle, forearm, hand, shoulder or abdomen. Regional anaesthesia is sometimes achieved by using a nerve-locating device, such as a nerve stimulator, or by using ultrasound. These devices help to locate the selected nerve(s) so that local anaesthetic can be delivered with improved accuracy. Regional anaesthesia may be used on its own or combined with general anaesthesia. Once local anaesthetic is injected in the desired region, patients may experience numbness and tingling in the area supplied by the nerves and it may become difficult or impossible to move that part of the body. The duration of the anaesthesia depends on which local anaesthetic is used, the region into which it is injected and whether it is maintained by continual doses or repeated injections. Typically numbness can last several hours but may last up to several days. Generally, the “heaviness” wears off within a few hours but the numbness and tingling may persist much longer. As the local anaesthetic effect wears off, numbness will diminish and surgical pain may return, in which case alternate methods of pain relief, including injections or tablets, will be prescribed. Sedation Conscious sedation is defined as a medication-induced state that reduces the patient’s level of consciousness during which the patient may respond purposefully to verbal commands or light touch. A variety of medications and techniques are available for procedural sedation and/or analgesia (sedation or pain relief which is administered to allow a specialist to perform a procedure). The most common medications used that are injected into a vein are benzodiazepines (which act on the brain and the nervous system) such as midazolam for sedation and opioids (which decrease the patient’s perception of pain), such as fentanyl, for pain relief. Deep levels of sedation, where patients lose consciousness and respond only to painful touch, may be associated with the patient having difficulty with breathing normally and their heart function may be affected. The anaesthetist is trained to manage these situations.

Pre-operative assessment Most planned surgery will involve the services of the nurse led pre-assessment process. After your surgeon has decided that you need an operation, you will be asked to fill out a health questionnaire. You will have to tick “yes” or “no” to questions about your health as it is now and if appropriate, in the past. If you see your surgeon in Whangārei you may be able to come to clinic and be seen by a nurse straight away. If you are seen in another hospital e.g. Dargaville, or do not have the time to visit the clinic, the booking clerk will ring you and make you an appointment. You may also have this appointment in Kaitaia. At the clinic the nurse will check your blood pressure, listen to your heart and lungs, record an ECG and order blood tests and x-rays if necessary. You will be given information about your anaesthetic, pain relief, what medications to take and what medications to stop. The nurse will give you her contact details so that you always have someone to call if there is a new problem with your health or if you have a question to ask. Based on the answers in the assessment booklet, patients may be contacted by phone or seen in the anaesthetic pre-assessment clinic by the specialist nursing team and if necessary, one of the medical anaesthetic team. Special tests or referral to other medical teams may be arranged at this stage to help with preparation for the forthcoming surgery. Pre-operative Assessment Clinic The clinic is situated in the Surgical Admissions Unit (SAU) and is run by five nurses. Your assessment appointment will last about an hour. If you have to see the anaesthetist (the doctor who puts you to sleep) then this will add to your time at the hospital. There is an anaesthetist available in clinic every afternoon. The clinic is open Monday to Friday and patients can be seen between the hours of 9am and 4pm. Patients are occasionally seen outside of these times by prior appointment. Conditions which may require you to be seen in clinic Diabetes Cardiac disease (heart problems) High blood pressure Asthma/bronchitis Thyroid problems Kidney disease Obesity Contacts: Shelley McMahon Clinical Nurse Specialist ext 8749 SAU ext 8770. Calls will be redirected to the appropriate Nurse Specialist. Pre-operative Assessment Clinic (PAC).pdf.pdf.pdf.pdf.pdf.pdf (PDF, 115.3 KB) A step-by-step guide for patients

Your anaesthetic will be given to you by a specialist doctor called an anaesthetist. Anaesthesia care falls into three parts: pre-operative visit, care during surgery and postoperative care in the recovery room. Preoperative visit on the day of surgery The anaesthetist and patient will meet on the day of surgery and occasionally before if you are already in hospital. The anaesthetist will make the final anaesthetic plan with you. It is their job to assess your suitability for the various types of anaesthetic. Both the nurses and doctor in the clinic ask about the following conditions, and the anaesthetist on the day of surgery may seek further information about any abnormal findings with you: general health, particularly heart and breathing problems previous anaesthetics received and any complications associated with these events previous general medical history medications, including which pills have been taken on the day allergies to drugs or lotions social habits e.g. smoking and alcohol consumption and exercise ability any health changes that have occurred since the pre-assessment appointment. Many of these issues will have already been covered by the pre-assessment team but a summary of the findings is essential for the anaesthetist who will be responsible for you at the time of surgery. A physical examination of your heart and lungs will be carried out. Your neck will be checked for shape and your mouth for loose teeth or caps. These are checked because if a breathing tube is to be inserted, it can sometimes be difficult to insert depending on the shape of the neck and mouth and also to prevent damage to teeth in the process. The anaesthetist may occasionally prescribe a pre-med, which is a medication taken prior to surgery, designed to aid in relaxation. Care During Surgery During the operation the anaesthetist's main roles are as follows: to optimise the conditions to make surgery as safe as possible for each patient to prevent pain - achieved by administration of pain relief agents appropriate for you and for the extent and duration of the operation. These may include pain relief medicines or nerve blocks to help numb the areas involved with the surgery to monitor oxygenation - this means ensuring that all vital organs are being adequately supplied with oxygen. This is assessed by skin colour, heart rate and your level of consciousness for patients having general anaesthetics, monitoring your breathing - assessed by the respiratory rate, volume of each breath and the inhaled and exhaled carbon dioxide concentrations. The anaesthetic gas and oxygen are delivered together either via a mask or breathing tube. If a mask is used the patient usually breathes on their own. If a breathing tube is used the patient may breathe on their own or be mechanically ventilated using an artificial ventilator to monitor circulation - during the operation, intravenous fluids and/or blood products are administered if necessary. Circulation is assessed by blood pressure, urine output and skin temperature to monitor the depth of anaesthesia when you are asleep. Postoperative Care When your operation is over, you will be taken to a special recovery area where your condition will be monitored as you wake up from the anaesthetic. The anaesthetic team will work with specialised nurses in PACU to make you comfortable and stable to facilitate the recovery after surgery.

Follow the directions given by the pre-assessment clinic staff as they will develop a plan specifically for you. If your GP or other health professional has started any new tablets, you must inform the pre-assessment clinic so that they can give you specific instructions about whether to take these medicines at the time of surgery. In general terms: What medicines should I stop or take prior to having surgery? As a general rule you should take your usual morning medications with a sip of water on the morning of the operation unless instructed otherwise by the anaesthetic team. It is important to cease some medicines prior to surgery, including blood-thinning drugs, also known as anti-platelet drugs (aspirin and clopidogrel), and anticoagulants such as warfarin. If a heart specialist has prescribed them, this will be reviewed in the clinic and a plan developed for your surgery. The decision about ceasing medications should be made primarily by the anaesthetic team in the pre-assessment clinic. They will talk with your surgeon and heart team to coordinate your care. It is vital that you do not stop taking these medications without specific instructions on when to stop and restart them. If your medical condition requires you to remain on blood thinners until surgery you may commence a shorter acting form of blood thinner and this process will be managed by the anaesthesia team. Diabetes medicines will also require a specific plan and this will be arranged for you with the anaesthesia team. These include various types of insulin or medicines taken by mouth to lower your blood-sugar level including metformin (DiaforminR, DiabexR) and gliclizide (DiamicronR). Your plan will vary depending on whether you have type 1 (insulin dependent) or type 2 diabetes (non insulin-dependent). The aim is to have good control of your blood sugar for surgery to help reduce infection and improve healing of tissues. Can I take herbal and dietary supplements? The use of herbal medicines is common. Herbal medicine is defined as a plant-derived product used for medicinal and health purposes; commonly used herbal supplements include echinacea, garlic, ginseng, ginkgo biloba, St John’s wort and valerian. Herbal medicines can have a variety of effects on surgery and interact with anaesthetic drugs. Ginkgo, ginseng and garlic all impair blood clotting and promote excessive bleeding. Prolongation of action of anaesthesia drugs can occur with valerian and St John’s wort. Herbal dietary supplements should be stopped two weeks prior to surgery. Fish oil supplements are also popular as a dietary supplement. They have potential in reducing cholesterol and hence may reduce the risk of heart attack and stroke. They also have anti-inflammatory properties and may be used to treat arthritis. The Therapeutic Goods Administration says that omega 3, which is found in fish oil, has no effect on bleeding and can be continued before surgery.

What are the risks of anaesthesia? While Australia and New Zealand are among the safest nations in the world in which to have anaesthesia, receiving multiple medications and altering normal human body function carries risks, some of which may be potentially life threatening. Risks and side effects include nausea and vomiting, physical injuries, reactions to drugs, awareness and even death. If you are concerned about these side effects please discuss them with your anaesthetist. Physical injuries Damage to teeth occurs in fewer than 1 in 100 general anaesthetic cases (Jenkins K, Baker AB. Consent and anaesthesia risk. Anaesthesia 2003: 58: 962-84). This usually occurs during a process known as laryngoscopy (inserting an instrument into the mouth), when a breathing tube is inserted through the vocal cords in your airway while you are asleep or if a plastic sucker has to be used to clear fluid in your mouth. The anaesthetist will take care during the anaesthesia and will examine your mouth prior to the operation and document the status of your teeth, including presence of caps, crowns, loose teeth or dentures. Sore throat Sore throat may occur in up to 45 per cent of patients having anaesthesia requiring a breathing tube known as an endotracheal tube, and in 20 per cent of patients when a laryngeal mask, which is a mask and tube that is inserted into the back of the throat, is used. The sore throat usually gets better by itself and may take a few days. Persistent sore throat may need to be referred back to the anaesthetist or reviewed by your doctor. Nerve injuries Nerve injury (damage to nerve fibres) following nerve blocks (regional anaesthesia) occurs in approximately 0.02 per cent or 1 in 500 cases (Jenkins K, Baker AB. Consent and anaesthesia risk. Anaesthesia 2003: 58: 962-84). Risks associated with epidurals are discussed under regional anaesthesia Blindness All complications are unfortunate and this complication is extremely rare, occurring in approximately one in 1,250,000 anaesthetics (Taylor TH. Avoiding iatrogenic injuries in theatre. BMJ 1992: 305: 595-6). Patients who are at a higher risk of blindness include smokers and those with high blood pressure or diabetes. Patients undergoing spinal and cardiac surgery involving cardiopulmonary bypass are at a higher risk than patients undergoing other types of surgery. If you have any of these conditions, discuss any concerns with your anaesthetist before your procedure. If you develop visual disturbance after your operation you should seek urgent medical attention. Death Death related to anaesthesia is extremely rare. Type of surgery (in particular if the surgery is an emergency such as for major trauma), underlying medical condition, physical status, and age all impact on the rate of death. According to the American Society of Anaesthetists (ASA) classification system, which is based upon the overall health of the patient, for a healthy patient (known as ASA 1) undergoing surgery the incidence of death is about one in 100,000. If combined, the incidence of death of patients with all different physical conditions, including those that are not expected to survive with or without the operation (ASA 4), is one in 50,000 (Contractor S, Hardman JG, Injury during anaesthesia, CEACCP, Volume 6, Number 2 2006). Could I react to an anaesthetic drug? It is possible to have an allergic reaction to medications given as part of anaesthesia. The reaction varies from a mild allergic reaction, such as a rash, to a life-threatening reaction called anaphylaxis, which is a severe life-threatening allergic reaction. The incidence of anaphylaxis reactions to anaesthetic agents in Australia is 1 in 10,000 to 1 in 20,000. Neuromuscular (nerve and muscle blocking medications are responsible for 70 per cent of the life-threatening allergic reactions during anaesthesia. In 80 per cent of reactions to these medications, there had been no previous history of use. Antibiotic medications and latex (rubber) are the other common causes of allergic reaction. Penicillin is the most common antibiotic to cause an allergic reaction. It is important that you tell your anaesthetist if you have experienced an allergic reaction to any medications in the past. Will I experience nausea or vomiting? In the past, nausea or vomiting were relatively common after general anaesthesia however with new and improved anaesthesia medication and delivery systems, and appropriate use of anti-nausea medication, there has been a reduction in the number of patients experiencing these symptoms. Postoperative nausea and vomiting (PONV) occurs in 20 to 30 per cent of the general surgical population and in up to 70 to 80 per cent of high-risk surgical patients. Risk factors for PONV can be divided into three categories: Patient-specific risk factors Female gender, non-smoking status, history of PONV/motion sickness. Anaesthesia risk factors Use of vapour anaesthesia. Use of nitrous oxide (gas). Use of intraoperative and postoperative opioid medications such as morphine. Surgical risk factors Duration of surgery (each 30 minute increase in duration increases PONV risk by 60 per cent). Type of surgery, for example laparoscopy (key hole), gynaecological (reproductive), ophthalmologic (eye surgery) and breast. Some studies report migraine, youth, anxiety and patients with a low ASA (American Society of Anaesthetists) risk classification as independent predictors for PONV, although the strength of these factors varies from study to study. Longer procedures under general vapour anaesthesia accompanied by longer exposure to the vapour anaesthesia and increased postoperative opioid consumption are associated with an increased incidence of PONV. Use of regional anaesthesia is associated with a lower incidence of PONV than general anaesthesia in both children and adults. It is important that you notify your anaesthetist if you have experienced nausea and vomiting after a previous anaesthesia. There are measures that can be taken to minimise the chance of I am frightened that I may be aware during an operation. Is that possible? This experience, known as “awareness”, is one of the biggest concerns for patients about to undergo surgery. Though it may worry patients, this condition can be almost entirely eliminated by the anaesthetist, with fewer than 1 in a 1000 patients remembering any part of their operation and most of these not recalling any pain. Conscious awareness without recall of pain is more common; it has been estimated at 0.1 to 0.7 per cent of cases (1 in 142 to 1 in 1000). Some operations are associated with a higher risk of awareness than others. They include cardiac surgery, emergency surgery, surgery associated with significant blood loss and caesarean section. Specialised monitoring equipment is available to assist anaesthetists to assess the depth of anaesthesia. Such equipment includes processed electro-encephalography such as Bispectral Index Scale (BIS) and Entropy, which record electrical wave patterns in the brain and assign a score which reflects the depth of unconsciousness. These monitors have been shown to reduce the incidence of awareness, particularly in high-risk cases. What is regurgitation and aspiration? Regurgitation is a passive process whereby the stomach contents are brought up into the oesophagus (food tube). It may occur at any point during anaesthesia. Aspiration is the inhaling of those contents into the lungs, where the acidic contents may damage the lung tissue. Several factors work towards regurgitation and aspiration happening, including emergency surgery, light anaesthesia, upper and lower gastrointestinal (gut) disease, obesity, gastroesophageal reflux (heartburn), impaired consciousness level and hiatus hernia of the stomach. Trauma, labour and opioid medications slow down stomach emptying. The anaesthetist will account for these factors and may perform a “rapid sequence induction”. In this procedure, 100 per cent oxygen is administered for several minutes before administering the drugs that put you to sleep. This fills your lungs with 100 per cent oxygen. The assistant to the anaesthetist will lightly press on your throat before any loss of consciousness to prevent any substances coming up from the stomach (regurgitation) and into the throat from where they can then be inhaled into the lungs (aspiration). Click this link for more options: http://www.anzca.edu.au/patients/frequently-asked-questions/risks-and-complications.html#what-are-the-risks

Click on this link for information http://www.anzca.edu.au/patients/frequently-asked-questions