Rothman Orthopaedic Specialty Hospital has partnered with United Anesthesia Services, a dedicated and experienced team of physician anesthesiologist and Certified Registered Nurse Anesthetists (CRNAs). The anesthesia team exists to provide optimal surgical conditions for the surgeon while ensuring patient safety and comfort. The following information is provided to establish patient expectations, knowledge and confidence regarding anesthesia.
General Anesthesia
General Anesthesia consists of the administration of medications either through intravenous infusion or inhalation (breathing) that will provide pain relief, muscle relaxation and sleep for the duration of surgery. In Pre-Op and prior to general anesthesia, patients undergo a complete pre-anesthetic evaluation which includes:
- review of experience with previous anesthetics,
- pertinent medical history,
- medication history, and
- brief physical examination.
While in Pre-Op, an intravenous (IV) infusion will be started, usually in the arm or hand. Sedative medications will be administered through the IV, blood pressure and heart monitors will be placed. Once completely asleep, an airway will be placed to ensure adequate breathing. Shortly thereafter patients are transported to the operating room where vital signs and state of awareness are continuously monitored by the anesthesia care team. At the conclusion of surgery, the airway will be removed, and patients are transported to the post-anesthesia recovery-unit (PACU) to gradually awaken. The anesthesia team in PACU will closely monitor vital signs and respiratory status while administering pain and anti-nausea medications as needed. When awake and comfortable, family members are encouraged to visit in PACU. Patients going home after surgery will be given small amounts of solids and liquids orally, and prepared for discharge. Patients remaining in the hospital for an overnight stay will be transported to the inpatient unit.
Side effects of general anesthesia include sleepiness and possible nausea. These effects diminish over a period of hours. Occasionally, patients experience other side effects as headache, difficulty voiding, and a sore throat possibly due to the airway used during surgery. Other risks of general anesthesia are related to particular patient characteristics, such as obesity, or cardiac, respiratory, kidney or liver disease. The procedures and risks of general anesthesia for you will be discussed with you prior to surgery.
Intravenous Sedation and Local Anesthesia
Intravenous sedation refers to medications injected through an intravenous (IV) infusion that results in sleepiness, analgesia (pain relief) and relaxation. These medicines are similar to those used for colonoscopy, and the resulting sedation is commonly referred to as “twilight”. Local anesthesia refers to the injection of numbing medicine commonly used by dentists. The combination of intravenous sedation and local anesthesia allows surgery to be performed painlessly and with minimal to no anxiety, while at the same time providing for rapid awakening and minimal side effects. Prior to intravenous sedation and local anesthesia, patients undergo a complete pre-anesthestic evaluation which includes:
- review of experience with previous anesthetics,
- pertinent medical history,
- medication history, and
- brief physical examination.
While in Pre-Op, an intravenous (IV) infusion will be started, usually in the arm or hand. Sedative medications will be administered through the IV, blood pressure and heart monitors will be placed. After patients are comfortable and sedated, local anesthesia will be injected by the surgeon. Shortly thereafter patients are transported to the operating room where vital signs and state of awareness are continuously monitored by the anesthesia care team. While patients may have some awareness during a procedure, it will be accompanied by a sense of relaxation and comfort and little will be remembered. At the conclusion of surgery, sedation will be discontinued, and patients are transported to the post-anesthesia recovery-unit (PACU) to gradually awaken. The anesthesia team in PACU will closely monitor vital signs and respiratory status while administering pain and anti-nausea medications as needed. When awake and comfortable, family members are encouraged to visit in PACU. Patients going home after surgery will be given small amounts of solids and liquids orally, and prepared for discharge. Patients remaining in the hospital for an overnight stay will be transported to the inpatient unit.
Side effects of intravenous sedation and local anesthesia include drowsiness and possible nausea. The surgical area may be numb. These effects will diminish over a period of hours. Occasionally, intravenous sedation and local anesthesia is not sufficient to provide total patient comfort, in which case general anesthesia may be required. The precise degree of sedation that can be safely provided for an individual patient depends on several factors, including the nature of the surgical procedure, and patient-related factors such as obesity and sleep apnea, and cardiac, respiratory or neurologic disease. The procedures and risks of intravenous sedation and local anesthesia will be discussed prior to surgery.
Total Joint Replacement Anesthesia (Hip & Knee)
Nearly all patients undergoing total joint replacement at Rothman receive spinal anesthesia with intravenous sedation. Spinal anesthesia provides optimal operating conditions for the surgeon, while providing the patient with comfort, safety and a rapid recovery enabling ambulation soon after surgery. Some patient characteristics, such as obesity or obstructive sleep apnea may alter some aspects of anesthesia. The anesthesiologist will discuss any concerns prior to surgery.
After registration a nurse escorts each patient to the Pre-Operative area. In Pre-Op, an intravenous infusion will be started for the administration of fluids and medicine during surgery. Patients are then taken to a procedure room where sedation will be given to induce relaxation followed by the administration of spinal anesthetic. The spinal anesthetic is an injection of numbing medicine into the lower back. While many patients are anxious about this procedure, it is usually rapid and virtually painless. Patients will notice their legs becoming warm, heavy and then numb. Once in the operating room, sedation medications will be given through the intravenous line. After approximately five minutes, most patients close their eyes and doze through the operation. At the conclusion of surgery, the intravenous sedation is stopped and patients awaken in the recovery room. Patient legs will remain numb for about an hour after surgery. When the spinal anesthetic starts to wear off, patients are transferred to a private room in the hospital. Pain medicine will be administered through intravenous infusion as needed. Frequently, additional medicines are administered with the spinal anesthetic or in the incision area to help you with postoperative discomfort.
All anesthetics are associated with side effects. With spinal anesthesia, patient blood pressure usually goes down. This is normal and usually advantageous for surgery. Patient blood pressure will be closely monitored. Spinal anesthesia has been associated with headaches. Occasionally, some patients, particularly males, may experience difficulty passing urine for a day or so postoperatively. This is more common in patients who already have some difficulty urinating. Probably the most common effect is mild discomfort, like a small bruise, at the site of the spinal needle insertion.
Nerve Block for Ankle, Elbow, Foot & Shoulder Surgeries
Most patients undergoing Ankle, Elbow, Foot or Shoulder surgery at ROSH will receive a nerve block along with general anesthesia (spinal anesthesia is sometimes used). In many cases, a continuous nerve block is also performed. A nerve block injection contains local anesthetic similar to Novocain that surrounds the nerves supplying sensation to the surgical area. These injections are done with minimal discomfort after sedation but before falling completely asleep. The nerve block causes the surgical area to be numb and possibly weak. The nerve block provides an extra measure of pain relief that extends for eight to ten hours after surgery. In many cases, pain relief can be extended further by the placement of a small tube or catheter adjacent to the nerves (done at the same time as the nerve block). This is called a continuous nerve block. After a nerve block is complete patients receive general anesthesia for the surgical procedure.
After surgery a small pump is attached to the catheter to infuse a small amount of numbing medicine around the nerves for up to two days post surgery. This pump is about the size of a grapefruit and works automatically without a need for electricity or manual manipulation. The pump is carried in a sling. Because there are no sutures securing the catheter, the patient must be careful to avoid snagging and displacing the catheter line. Since the medicine in the pump is only half the strength of the original nerve block medicine, patients will regain some sensation and strength after about eight to ten hours. Prescribed oral pain medication must be taken in conjunction with the pump to achieve effective pain relief. The catheter does not provide 100% pain relief. After about two days, the pain pump will be empty and can be removed by the patient at home. The decision to receive a nerve block is based on the surgical procedure and patient preference. Patients will receive a complete set of written and verbal instructions the day of surgery explaining the nerve block and postoperative pain management.
