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Anaesthesiology Services

At Precision Urology Hospital, we are committed to keep our patients pain-free and comfortable during medical procedures. Our anesthesia team, headed by Dr. Vandana Mishra, helps us diligently in that cause since anesthesia temporarily blocks sensory/pain signals from nerves to the centres in the brain. The Critical Care Department has full time anesthetists who handle high dependency patients in medical and surgical ICU.

Who performs anesthesia at PUH?

  •  If you’re having a relatively simple procedure like a kidney biopsy, prostate biopsy or percutaneous nephrostomy placement,  that requires numbing a small area, the treating urologist/nephrologist performing your procedure can administer the local anesthetic.
  • For more complex and invasive procedures, your anesthetic will be administered by a physician anesthesiologist. This medical doctor manages your pain before, during, and after surgery.
  • In addition to the physician anesthesiologist, the anesthesia team may include physicians in training (fellows or residents), a certified registered nurse anesthetist (CRNA), or a certified anesthesiologist assistant (CAA).

What are the types of anesthesia that we administer?

The anesthesia used depends on the type and scope of the urologic or nephrological procedure. The options include:

  • Regional anesthesia: This type of anesthesia blocks pain in a large part of the patient’s body, such as an upper limb for Basalic transposition or everything below the chest for stone surgery. During the procedure, the patient may be conscious or have sedation in addition to the regional anesthetic. For example, an epidural to ease the pain of open bladder cancer surgery, a spinal for PCNL, or an arm block for AV fistula surgery.
  • General anesthesia: This treatment makes the patient unconscious and insensitive to pain or other stimuli. General anesthesia is used for more invasive surgical procedures such as urological laparoscopic surgery, or procedures of the kidney where movement has to be restricted.
  • Sedation: Sedation relaxes the patient to the point where he/she will have a more natural sleep but can be easily aroused or awakened.

           o   Light sedation can be prescribed by the person performing the procedure or together with a regular nurse trained in providing moderate sedation. For example, procedures performed with light or moderate sedation include DJ stenting and cystoscopy.

           o   Deep sedation is provided by the physician anesthesiologist because the patient’s breathing may be affected with the stronger anesthetic medications. Although the patient will not be completely unconscious, they are not as likely to remember the procedure.

How is anesthesia administered at PUH?

Depending on the procedure and type of anesthesia needed, the healthcare provider may deliver the anesthesia via:

  • Inhaled gas
  • Injection, including shots or intravenously (IV)
  • Topical (applied to skin) liquid, spray or patch

How should I prepare for anesthesia?

  • Make sure your healthcare provider has a current list of the medications and supplements (vitamins and herbal medications) you take. Certain drugs can interact with anesthesia or cause bleeding and increase the risk of complications.
  • Avoid food and drinks for eight hours before you go to the hospital unless directed otherwise.
  • Quit smoking, even if it is just for one day before the procedure, to improve heart and lung health. The most beneficial effects are seen with no smoking for two weeks before.
  • You should take certain (but not all) blood pressure medications with a sip of water as instructed by your healthcare provider.
  • Omit anti diabetic drugs on the day of surgery. Remove all ornaments before going to the operation theatre.

What happens during anesthesia?

A physician anesthesiologist:

  • Administers one type or a combination of anesthetics, and possibly anti-nausea medications.

  • Monitors vital signs, including blood pressure, blood oxygen level, pulse and heart rate.

  • Identifies and manages problems, such as an allergic reaction or a change in vital signs.

  • Provides postsurgical pain management.

What are the potential side effects of anesthesia?

Most anesthesia side effects are temporary and go away within 24 hours, often sooner. Depending on the anesthesia type and how providers administer it, you may experience:

  • Back pain or muscle pain

  • Chills caused by low body temperature (hypothermia)

  • Difficulty in urinating

  • Fatigue

  • Headache

  • Itching

  • Nausea and vomiting

  • Pain, tenderness, redness or bruising at the injection site

  • Sore throat (pharyngitis)

What are the potential risks or complications of anesthesia?

  • Anesthetic awareness: For unknown reasons, about one out of every 1,000 people who receive general anesthesia experience awareness during a procedure. You may be aware of your surroundings but unable to move or communicate.

  • Collapsed lung (atelectasis): Surgery that uses general anesthesia or a breathing tube can cause a collapsed lung. This rare problem occurs when air sacs in the lung deflate or fill with fluid.

  • Malignant hyperthermia: People who have malignant hyperthermia (MH) experience a dangerous reaction to anesthesia. This rare inherited syndrome causes fever and muscle contractions during surgery. It is important to relate a personal or family history of MH to your physician anesthesiologist before your anesthetic to avoid drugs that trigger this reaction.

  • Nerve damage: Although rare, some people experience nerve damage that causes temporary or permanent neuropathic pain, numbness, or weakness.

  • Postoperative delirium: Older people are more prone to postoperative delirium. This condition causes confusion that comes and goes for about a week. Some people experience long-term memory and learning problems. This condition is known as postoperative cognitive dysfunction.

Certain factors make it riskier to receive anesthesia, including:

  • Advanced age

  • Diabetes or kidney disease

  • Family history of malignant hyperthermia (anesthesia allergy)

  • Heart disease, high blood pressure (hypertension) or strokes

  • Lung disease, such as asthma or chronic obstructive pulmonary disease (COPD)

  • Obesity (high body mass index or BMI)

  • Seizures or neurological disorders

  • Sleep apnea

  • Smoking

How long does it take to recover from anesthesia?

Anesthetic drugs can stay in your system for up to 24 hours. If you’ve had sedation or regional or general anesthesia, you shouldn’t return to work or drive until the drugs have left your body. After local anesthesia, you should be able to resume normal activities, as long as your healthcare provider says it’s okay.

Why is general anesthesia given?

Your anesthesiologist, along with your doctor, will recommend the best anesthesia option for you based on the type of surgery that you will be undergoing, your overall health and your individual preferences. For certain procedures, your team may recommend general anesthesia. These include procedures that may take a long time, result in significant blood loss, expose you to a cold environment, or affect your breathing (particularly chest or upper abdominal surgery).

At PUH, in what type of cases is general anesthesia given?

We prefer to give general anaesthesia for following operations:

  • Kidney transplant surgery
  • Stone surgery- RIRS
  • Open surgeries for cancer
  • Laparoscopic urology cases
  • Pediatric urology cases

What are the risks associated with general anesthesia?

General anesthesia is overall very safe; most people, even those with significant health conditions, are able to undergo general anesthesia itself without serious problems.

Older adults, or those with serious medical problems, particularly those undergoing more extensive procedures, may be at increased risk of postoperative confusion, pneumonia, or even stroke and heart attack. Specific conditions that can increase your risk of complications during surgery include smoking, seizures, obstructive sleep apnea, obesity, high blood pressure, diabetes, stroke, other medical conditions involving your heart, lungs or kidneys, medications, such as aspirin, that can increase bleeding, history of heavy alcohol use, drug allergies, history of adverse reactions to anesthesia.

These risks are more generally related to the surgery itself rather than the anesthesia.

How should you prepare for General Anesthesia?

General anesthesia relaxes the muscles in your digestive tract and airway that keep food and acid from passing from your stomach into your lungs. Always follow your doctor's instructions about avoiding food and drink before surgery. 

Fasting is usually necessary starting about six hours before your surgery.

Your doctor may tell you to take some of your regular medications with a small sip of water during your fasting time. Discuss your medications with your doctor.

You may need to avoid some medications such as aspirin and some other over-the-counter blood thinners for at least a week before your procedure. These medications may cause complications during surgery.

If you have diabetes, talk to your doctor about any changes to your medications during the fasting period. Usually, you will be asked not to take oral diabetes medication on the morning of your surgery. If you take insulin, your doctor may recommend a reduced dose.

If you have sleep apnea, discuss your condition with your doctor. The anesthesiologist will need to carefully monitor your breathing during and after your surgery.

What can you expect before, during, and after the procedure?

Before the procedure

Before you undergo general anesthesia, your anesthesiologist will talk to you (perform pre anaesthetic check up) and may ask questions about:

  • Your health history
  • Your prescription medications, over-the-counter medications and herbal supplements
  • Allergies
  • Your past experiences with anesthesia

This will help your anesthesiologist choose the medications that will be the safest for you.

During the procedure

Your anesthesiologist usually delivers the anesthesia medications through an intravenous line in your arm. Sometimes you may be given a gas that you breathe from a mask. Children may prefer to go to sleep with a mask.

Once you're asleep, the anesthesiologist may insert a tube into your mouth and down your windpipe. The tube ensures that you get enough oxygen and protects your lungs from blood or other fluids, such as stomach fluids. You'll be given muscle relaxants before doctors insert the tube to relax the muscles in your windpipe.

Your doctor may use other options, such as a laryngeal airway mask, to help manage your breathing during surgery.

Someone from the anesthesia care team monitors you continuously while you sleep. He or she will adjust your medications, breathing, temperature, fluids and blood pressure as needed. Any issues that occur during the surgery are corrected with additional medications, fluids and, sometimes, blood transfusions.

After the procedure

When the surgery is complete, the anesthesiologist reverses the medications to wake you up. You'll slowly wake either in the operating room or the recovery room. You may experience common side effects such as rigors, nausea, vomiting, dry mouth, sore throat, muscle aches, itching, shivering, sleepiness, and mild hoarseness.

You may also experience other side effects such as pain after you wake up from anesthesia. Your anesthesia care team will ask you about your pain and other side effects. Side effects depend on your individual condition and the type of surgery. Your doctor may give you medications after your procedure to reduce pain and nausea.

What is spinal anaesthesia?

Spinal anaesthesia can be used for most operations below the waist. A very fine needle is inserted into the middle of the lower back and local anaesthetic is injected through the needle into the fluid that surrounds the spinal cord. The local anaesthetic numbs the nerves that supply the tummy, hips, bottom and legs. Once the nerves are completely numb, you will not feel any pain from an operation and you will also not be able to move your legs. Other medications can also be injected which provide excellent pain relief for several hours after the operation.

What operations may be performed under spinal anaesthetic?

Various urological operations can be performed under spinal anaesthesia. These include stone operations of kidney (PCNL), kidney removal, stones in ureter and bladder, open surgery for bladder, TURP and other endoscopic operations of prostate and urethra.

Do I have different options when having a spinal anaesthetic?

Yes, there are various options. Your anaesthetist will see you before the operation to discuss all the options with you. The anesthetist will help you come to a decision regarding the best option for you.

  • Spinal anaesthesia alone: With this option you would be awake during the operation and will be able to hear what is going on in the operating theatre but NOT BE ABLE TO FEEL ANY PAIN. You may, however, have a sensation of movement or pressure - this is entirely normal. A screen will be put up so that you will not be able to see the operation.

  • Spinal anaesthesia with sedation: In this instance, once the spinal anaesthesia has been performed and the anaesthetist is happy with the block, the anaesthetist will give some medication into your drip to make you feel relaxed and sleepy. This is NOT a full general anaesthetic and you may, from time to time, be aware of voices and other general theatre activity but you will NOT FEEL ANY PAIN.

  • Spinal with general anaesthesia combined: In some situations the anaesthetist might feel that a combination of a spinal anaesthetic and a general anaesthetic is the best option for you. Also in some situations (for example, if the operation takes an unexpectedly long time or you start to feel discomfort during the operation) it might be necessary to add in a general anaesthetic to overcome these issues.

How is the spinal anaesthetic given?

The spinal anaesthetic will be performed in the anaesthetic room or in theatre.

There will be an operating department practitioner to assist the anaesthetist and another member of the theatre team to support and help you during the procedure.

Before the spinal anaesthetic is given, the anaesthetist will put a drip (cannula) in your hand and you will be attached to a monitor (ECG, blood pressure and oxygen saturations).

Most often, the spinal anaesthetic will be done whilst you are awake. Your anaesthetist will instruct you as to what position you need to get into for the procedure to be done. This will be in one of two positions:

  • In a sitting position with you slumped forward, chin on your chest, shoulders down and bottom curled under.

  • Lying on your side with your knees curled up towards your chest.

These positions help to open up the spaces between the bones in your back, which is where the anaesthetist needs to put the spinal anaesthetic.

Once you are in the correct position your back will be cleaned with antiseptic, the anaesthetist will scrub their hands and put on a surgical gown, gloves, hat and mask. These steps help to minimise the risk of infection.

The anaesthetist will feel your back quite firmly to identify certain landmarks and identify where exactly the spinal anaesthetic needs to be inserted.

Local anaesthetic will firstly be injected to numb the skin; then the fine spinal needle will be inserted.

At this point it is particularly important to keep very still. You should not feel significant pain; however, if the needle goes close to one of the nerves that supply your legs you may feel a shooting pain down one of your legs. If this occurs, it is important that you keep still and let your anaesthetist know, telling them which leg you felt the pain in.

Once the medication has been injected, you will feel a warm tingly sensation in your bottom and your legs will start to go numb.

The spinal anaesthetic doesn't work instantly; it takes approximately 5-15 minutes to work. You will also start to feel that it is difficult to move your legs, and eventually not be able to move your legs at all.

What happens after a spinal anaesthesia?

After a period of time, the effect of the spinal anaesthetic will wear off. You will gradually start to be able to feel and move your legs. You may experience tingling or pins and needles in your legs as the spinal anaesthetic wears off.

The length of time that the spinal anaesthetic takes to wear off will depend on the medications that the anaesthetist uses for the spinal anaesthetic. Usually the block will have worn off in four hours and you will be able to get out of bed six hours after the spinal anaesthetic.

Often the anaesthetist will add pain-killing medication to the spinal anaesthetic to give pain relief after the operation. These effects last after the feeling and movement have returned to your legs.

What are the advantages of a spinal anaesthetic?

There are some medical conditions that make having a general anaesthetic (GA) more risky - for example, significant breathing problems. Your anaesthetist will discuss the options with you and help you decide which option is best suited to your particular situation. The following are the advantages of having a spinal anaesthetic:

  • Less risk of getting a chest infection after the operation

  • No detrimental effect on the lungs and breathing

  • Excellent pain relief immediately after the operation

  • Reduced need for strong painkillers which can cause a feeling of sickness (nausea), being sick (vomiting), confusion and constipation

  • No 'hangover' effect from the GA

  • Less risk of confusion after the operation, especially in elderly patients

  • Less nausea or vomiting, which can be caused by the GA medications

  • Being able to eat and drink sooner after the operation

What is post spinal headache?

You might get a particularly bad headache that is caused by the spinal anaesthetic. This happens in 1 in 200-300 spinal anaesthetics but it is much less likely in an older person. This headache feels different to normal headaches in that it gets worse when you sit/stand up and better when you lie down. Normally this type of headache resolves with rest, drinking plenty of fluids and taking simple painkillers.


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