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Thursday, July 10, 2008

Anesthesia Concerns

Okay, I'm coming up for air. My first week of clinicals is over, and it went very well. It was even fun at times! It's definitely terrifying, but it should be at this stage of the game, and that's why there's a CRNA with me at all times for the first year in the OR.

I do have to get up early tomorrow morning but only for an hour, and then I can get some more sleep, so I wanted to answer a reader question (or questions) about band surgery and anesthesia. I don't want to portray myself as an expert by any means, but being in my nurse anesthesia program, I do think I can answer some of these questions at least to some extent.

The questions, to summarize, were basically these: is it easy to detect a reaction to anesthesia, and how dangerous is it; does recent inflammation of airways increase risk during anesthesia; how common is it to wake up during surgery; and does coughing affect the band? These are all great questions, and I'll answer them as best I can.

First, about reactions to anesthesia: it depends on what kind of reaction you mean. Some people describe a reaction to anesthesia as something that happens while you are being anesthetized, during your surgery, that happens as a direct result of the anesthetic medications or procedures. Others would include things like post operative nausea and vomiting, which can be due to anesthesia but happen afterward, and are rarely life threatening. Most reactions that can occur during surgery are fairly easy for an experienced anesthesia provider to detect and treat. As far as safety is concerned, anesthesia has become extremely safe in recent years, due to improvements in technology and medications as well as the high degree of skill required by practitioners.

I've heard anesthesia risk described by an anesthesiologist this way: It's sort of like driving a car. It's very unlikely that anything will happen at all, but if something does go wrong it's usually fairly minor, say a flat tire or even a fender-bender. There is the risk that you will get in a big accident and die, but that risk is very, very low--we drive cars every day, all over, and that rarely happens to any one individual. That's a pretty good description of anesthesia risk (for most people, in most situations)--the likelihood of something going wrong is low, but it can, and on very rare occasions it can be life threatening or fatal. That's not meant to scare you at all, but just let you know that it's possible, but unlikely.

A recent cold or bronchitis can make your airway more reactive during anesthesia. The risk of having a "reactive airway" (one that doesn't respond favorably to having a breathing tube inserted) goes up if you have preexisting pulmonary problems (like emphysema or asthma) or if you are a smoker. I believe the current recommendation is that upper respiratory infections should be cleared up for 2 weeks prior to having anesthesia, but your anesthesia provider may tell you something different based on their own experience and their assessment of you. You might want to ask your surgeon about this now if you are within 2 weeks of your surgery date. (You probably won't have an anesthesia provider assigned until the week of surgery, probably the day before, and they usually visit with you just prior to surgery, although you might go see them a day before.) Especially if you have bronchitis right now, I would want to make sure that is completely cleared up before having anesthesia.

For lap band surgery, which is laproscopic, you have to have an endotracheal tube inserted in your trachea--often called a breathing tube. This happens after you are put to sleep, but if your airway has recently been inflammed by bronchitis or a respiratory infection, you may be at more risk for spasms in your airway during or after surgery, which can impair your ability to get oxygen. Obviously that isn't something you want. In addition, obesity makes intubation more difficult, and we often have other problems like sleep apnea that make our anesthesia more difficult when we have bariatric surgery. When an anesthesia provider prepares to care for a patient undergoing bariatric surgery, the first concern they have is usually the airway, because it can be very difficult to manage an obese person's airway. When you add to that a recent bronchitis, the anesthesia provider's red flags go way up. So my recommendation, based on what you've told me, would be to talk to your surgeon and be prepared to delay your surgery by a week or two, to ensure that your bronchitis is completely recovered. This is elective surgery, after all, and you want to optimize your health so you can be successful and recover quickly. It's not like you have to have an emergency triple bypass right now, and can't take the time to make sure you're as healthy as possible. (Of course, most of us don't really feel like this surgery was THAT "elective"...but in terms of surgery, it is.)

Next, waking up during surgery, or "anesthesia awareness" as we call it...Yes, it is very rare. It happens mostly during surgeries in which the patient can't be very deeply anesthetized with gas or IV drugs, like traumas or vascular surgery where the patient has a very low blood pressure and can't tolerate very deep anesthesia. Even in those cases, it is very rare. We have a lot of ways to make sure that you are asleep and will not wake up during surgery. During this surgery, you will most likely receive IV anesthesia at the beginning and gas during the surgery (some people do an entirely IV technique), plus you will get a lot of narcotic medication during the surgery to ensure that you are not in any pain. You'll also get at least one medication for nausea during the surgery, probably more than one, to reduce any chance of post operative nausea or vomiting. (You might have some anyway, because of the band being placed on the stomach, but most people with the band don't seem to report it, and I didn't have any nausea after my band surgery.)

Finally, coughing with the band. I haven't had any problems since being banded last March. I suppose that it is possible that the band could move with very vigorous coughing, but the stomach is stitched over the band itself, and it usually doesn't move unless there is too much pressure from INSIDE your stomach--like when you have a too-tight fill and are barfing up food, that creates a lot of pressure in your stomach and can cause a band slip. I haven't heard of anyone having a band slip from coughing, but I heard of one woman who had her band slip and had to have it removed after she lifted a very heavy trundle bed (like over 400 lbs, with someone else of course!). They weren't totally sure that was the cause but it happened right before her slip. That is very rare. The best way to prevent having a band slip is by never allowing your fill to be too tight--meaning that you are always able to eat solid lean protein without barfing it back up (or "PBing" as the slang is in the lap band world). Right after surgery, they will ask you to cough and deep breathe frequently--at least 10 times an hour--to make sure your lungs stay healthy after your anesthesia. You'll be coughing right after surgery, and it won't affect your band at all. If you do get very sick and your coughing is so much that you are really concerned about your band, you can always call your band surgeon and ask if there is a problem, or if you should take some cough medicine--although in general, it's best not to suppress a cough with medicine, as that is how your body is trying to fight an infection.

I hope this helps answer some of your questions. Good luck with your band surgery! Do talk to the surgeon about whether it should be rescheduled due to your bronchitis. And let us know how everything goes when you are all done!


PennyLane said...

Thanks, Gwen that really helps.

I saw my surgeon and anesthesiologist (the program has a dedicated anesthesiologist) for my last pre-op appointment. I told them that I was currently sick (and had a great coughing fit in front of the anesthesiologist) and about to start antibiotics for it.

They said to call the Friday before my surgery (which is on Monday the 21st) and if I haven't made a full recovery by then, we'll have to reschedule.

I really really don't want to reschedule for a variety of emotional and logistical reasons but I also don't want to have problems in surgery. I'm just doing what I can to get healthy but nothing seems to be working! I haven't been this sick since I had pneumonia 10 years ago--talk about bad timing.

Thanks again for your help, I'll keep reading!

Nikki Leigh said...

Hi Gwen

I couldn't find an email address, so I'm contacting you here - I hope that is all right.

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