What Happens To You Under General Anesthesia?

Anesthesia is a relatively new field of science, although there were some trials in the past by pharaohs and Muslim scientists where they mostly used opium as a sedative and analgesic or ether as in the case of Muslim scientists but all these trials were not systematic and didn't get much luck in being used on a wide scale.

The father of modern anesthesia was actually a dentist called (William Morton) who managed to prove that (Ether) is a better anesthetic than (Nitrous Oxide) gas which dentists used to anesthetize their patients back in these days and they are still using it till now. This was in 1984 where Dr. Morton managed to anesthetize a patient to let the surgeon (Dr. John Collins Warren) operate on the patients and this was the first successful trial to anesthetize a patient during surgery in modern history.

Anesthesia got evolved in these relatively few years of action as we invented modern ventilators, better and more stable anesthetic gases, opioid analgesics, muscle relaxant drugs, and also intravenous anesthetics.

Everyday there are thousands of patients who go through surgical procedures under general anesthesia. You could have experienced such experience or yet to experience it and you would probably think that anesthetists are some sort of magicians who push some magical button to turn you off and then press it again to turn you on (like getting you awake not the other turn on).

This idea that most people have regarding general anesthesia has led to some public conclusion that general anesthesia is much better than any other alternatives like spinal and local anesthesia. As an anesthetist, I have dealt with thousands of patients who would generally prefer general anesthesia over regional anesthesia because they just want to sleep and forget about the whole surgery then wake up again when everything is done. 

I decided to write this article to put you in front of the real picture and let you informed of what really happens to you under general anesthesia and how risky the procedure is hoping to add something to your knowledge and make you think again before you deal lightly with general anesthesia.

First of all let me tell you about the job classification of an anesthetist. Anesthetist is a doctor who specializes in anesthetizing patients during surgeries, intensive care for patients, and pain relief. This previous classification may hint you about the true nature of anesthetist job in many countries around the world where he is usually dealing with risky situations that need rapid reaction in maintaining patient's airway patent and the circulation going. These situations don't just happen due to road traffic accidents or falling from heights but it can also occur under general anesthesia to almost any patient even if he looks apparently in good shape. The main reason for these emergency situations could be the anesthetic technique and drugs themselves.

At the end of any casual surgery you would wake up with some pain, some blood on the floor over here and there, some dirty clothes and surgical instruments, and the smiley face of your anesthetist looking at you in inverted manner.

What happened here?

We need to admit that the reason behind public ignorance about the process of anesthesia could be mainly referred to anesthetists themselves due to their solid personalities and lack of communication skills, this could be the main reason for anesthetist to specialize in anesthesia because he would be simply not loving to communicate much with patients and prefer them sleeping rather than awake.

Still asking what happened here? OK, now we will try to introduce you to general anesthesia and it starts with drugs:

The modern theory of anesthesia is based mainly on four components or four categories of drugs that should be combined together to produce sufficient anesthesia and analgesia for you to stand the surgery and wake up in good health.

1- Anesthetic drugs:

These drugs are responsible for making you lose consciousness, they are either intravenous anesthetics like this white drug in the picture which is fairly popular and it is called (propofol). Remember Michael Jackson's death? well, he was addicted to this drug and he lost his life because he probably injected himself with a big amount that was sufficient to make him lose his breath, we call that "propofol apnea" and it's very common to occur and it needs an anesthetist to maintain patient's breathing using some breathing bags and mechanical ventilators. Some other intravenous anesthetics come in transparent forms (ketamine) or yellowish forms (Thiopental) but we won't go through much details here. I just wanted to put your feet on the first step of general anesthesia which could be very risky if the anesthetist fails to maintain patient's airway like some morbidly obese patients who have higher chances to get obstructed after administration of intravenous anesthetics. These drugs are also relatively short acting (around 5 minutes in propofol and up to 20 minutes with ketamine) so we will need either to re-administer the patient with the same drug over and over or switch to anesthetic gases.

The second group of this category is inhalational or (volatile) anesthetics. These are the anesthetic gases we use to maintain the patient's sleep state during the whole surgery. Remember that ether we mentioned earlier? we don't use that for sure nowadays, instead we use more advanced drugs like (sevoflurane and desflurane). These inhalational anesthetics could be harmful to some patients too and they are not completely safe. 

For your knowledge, it is really hard to put people to sleep using inhalational gases alone and unlike American movies it would need to patient to be tied to the table with great concentrations of gases delivered to his lungs through a sealed circuit and this will take some minutes to make them sleep and not for long time if the concentration is lost at some point. It is very unlikely for you to lose consciousness after inhaling some of these gases and I do that all the time anyway and never lost my consciousness.

Propofol ampule

2- Opioids:

These drugs are extracted from plant origins or synthesized in equivalent analogues of the original drug. We use these for analgesia and they mostly cause addiction when abused. They might be dangerous too as some of them may cause allergic reactions and some others like morphine will cause patient's respiratory center depression, meaning they should be monitored carefully upon administration as the patient could lose his breath anytime of airway isn't maintained well. 

3- Muscle relaxants:

These drugs we use for putting patient muscles to artificial paralysis to put them on mechanical ventilation and allow the surgeon to operate efficiently on the patient without any sudden movements. This means your anesthetist will cut off your normal breathing and put you on a device that maintains your breathing. If the circuit fails at any time without proper monitoring by anesthetist this will cause certain death to the patient.

Many accidents occurred during anesthesia where the respiratory circuit was disconnected and the patient suffocated due to lack of normal motor power of breathing, we don't wish you that and it is certainly anesthetist fault but as we said, we are just informing you of the risks you are facing during general anesthesia.

4- Drugs of amnesia:

Anesthetists use these drugs to make the patient lose the memory of surgery. Some patients would accidentally wake up during surgery and again (it is anesthetist fault) but faults happen, isn't it? In that case these drugs will help to eliminate these bad memories you get during surgeries and will also give you some sedation upon surgery.

These drugs, like opioids, are not preferred to use in parturient mothers undergoing caeserian section, it would cause the baby to have difficulty in breathing if administered before delivery. Anesthetic drugs don't just harm the mother could could be transferred to baby's circulation too through placenta if the wrong drugs are administered.

Volatile anesthetic vaporizers

These were the main categories of drugs used for general anesthesia but as we said, anesthetic field of expertise requires the use of many other drugs to deal with risky situations. These drugs could be used anytime during anesthesia and here we give you some hint about it:

1- Some drugs are meant to control the heart rate and blood pressure of the patient as most of anesthetic drugs may cause the patient's heart rate or blood pressure to drop. It is not anesthetist fault now but this is the nature of most of these drugs. Atropine, ephedrine, epinephrine, and noradrenaline are common drugs to be used by anesthetists to maintain patient's own circulation ongoing and their hearts beating. 

Some patients with weak hearts like old patients and rheumatic heart patients will need very careful attention when administering anesthetic drugs due to higher risk of their hearts to stop beating and fail to compromise the depressing effect of anesthetic drugs. 

2- Intravenous fluids:

Anesthetist will have to compensate your body with fluids on regular basis. You lost some fluids due to your 6-8 hours fasting before surgery (you will be fasting for 6-8 hours before surgery if you don't know that), you also lose some of your body fluids due to evaporation during surgery, patients also might lose some of their blood especially in traumatic lesions and surgeries operating on blood rich organs. 

Anesthetist will have to calculate all your body fluid losses and compensate them with his wide variety collection of fluids like Ringer's solution, normal saline, voluven, plasma and blood components. It's anesthetist's job to keep you alive rather than keeping you asleep.

3- Other drugs:

like anti-emetics, anti-inflammatory drugs, broncho-dilators, and non-opioid analgesics. Patients could suffer nausea, vomiting, suffocation, allergic reactions to any drugs, and even pain as side effects of both general anesthesia and surgery itself and your anesthetist will have to deal with that too.

Now that you have some idea about anesthetic drugs, we will have to explain some tools used by anesthetists to get you ready for surgery:

1- Intravenous cannula:

This might be the first and last painful stick you will feel during the whole surgery (thanks to our dear anesthetist). Intravenous cannulation is a must for all surgeries and it is the standard starting point of your anesthesia. Your anesthetist will use that small needle in your veins to inject you with some drugs that will make you sedated and put you to sleep later on, also he will use that to give you fluid compensations like we said before.

Some patients could be very difficult to cannulate due to lack of proper veins and then our dear anesthetist will be in trouble and will likely stick the patient many times before successfully putting some cannula to your veins. If you get stitched many times don't hate your anesthetists, you might have difficult veins to cannulate at the end. This one is mostly your fault ;)

2- Endotracheal tube:

This plastic or silicon tube like the picture below will be put inside your trachea to maintain your airway patent. Your anesthetist will put it in your throat  (no offense) after you fall to sleep to keep you safe from having accidental obstruction of your trachea and lung, we call that securing airway.

If you ever get general anesthesia and wake up with your throat hurting and having dry cough, this could be due to this tube in case you wonder, medical manufacturers try to make it as soft as they could but it can still hurt some patients especially those with a sensitive oral mucosa.

Your anesthetist will use some device called (larungoscope) to put that tube in your trachea, it's a sharp metal blade and requires high training to be able to perform this step of anesthesia but never mind, you won't see it anyway.

Endotracheal intubation

3- Mechanical ventilator:

This big machine in the operating room, probably the biggest one, is responsible for replacing your tiny little lungs during the surgery. It will supply you with accurate breath volume and rate and also inhalational anesthetics we mentioned before. 

Any failures of this device are fatal and could lead to major harmful outcomes to the patient, no wonder they are big and very expensive. Your Anesthetist will calculate the right amount and frequency of breaths you should take and will get you supplied with oxygen, air, and nitrous oxide too.

4- The monitor:

This device monitors your vital signs like blood pressure, heart rate, oxygen saturation, electrocardiogram (ECG), your temperature, your carbon dioxide content, and many other vital signs according to how advanced this monitor device is.

Your anesthetist will keep an eye on you during the whole surgery watching your vital signs on this monitor and listening to your heart beebs. So, only your anesthetist besides your girlfriend will listen to your heart ;)

5- Some other devices: like suction devices to keep you safe from aspiration with your own gastric contents and some other sophisticated machines we use for replacing your cardiac functions in case of open heart surgeries.

Now, we have to introduce you to the sequence of events that happened to you when you were asleep:

1- Your anesthetist will begin with intravenous cannulation like we said, he might administer you with some sedative and anti-emetic drugs, he might take some medical history from you before operating on you. Will ask you about any medical conditions, any drugs you take, and any previous events regarding allergy to drugs or family history with medical conditions related to anesthesia.

2- You will be introduced to the operating room, your anesthetist will start attaching monitoring wires and devices to your body, will give him a hint upon starting the procedure. He will check your current vital state and will check if your heart rate is regulated and your blood pressure is controlled.

3- Now he will hold some breathing mask upon your face like the first image in this article, take a deep breath before he or another assistant will start injecting you with anesthetic drugs.

4- Now that you have lost consciousness, your anesthetist will start with putting that endotracheal tube inside your trachea, you can't stand that step awake so we put you to sleep before doing it.

5- After securing your airway and your intravenous access, your anesthetist will attach you to the breathing circuit connected to the mechanical ventilator.

6- He will start adjusting the right number and amount of breaths you should take as you have completely lost control over your body and handed it to your anesthetist.

7- He will adjust fluids and drugs you will take during general anesthesia.

8- Now that everything is stable he will grab a seat and sit beside you watching over you and your vital signs to make sure you are safe all the time.

9- Now, your surgeon is allowed to operate on you safely. You will go through surgery and your anesthetist will always be by your side.

10- From time to time, your anesthetist will inject you with some boaster doses of drugs he injected previously or some other drugs, some from here and some from there but don't worry, he knows what he's doing. Sometimes he will take some blood samples from your body and he might also adds another intravenous cannula somewhere else in your body but you won't feel the needle stick that time.

11- Now the surgery is finished safely, your anesthetist will cut off the inhalational or intravenous anesthetic supply to allow you to wake up.

12- you are still on mechanical ventilation until your prove worthy of taking back control over your body. your anesthetist will inject you with some drugs that will oppose the action of the previously administered drugs (the ones that paralyzed you) to help you recover your breathing functions efficiently.

13- You will be awaken and that awful endotracheal tube will be taken out of your throat, hey - what's your name? say your prayers, you are now officially awake.

14- Your will be put in recovery room for your anesthetist to watch you over to make sure you are fully recovered and then he will permit you to be discharged to your ward.

This was an extremely brief description of what happened to you during general anesthesia, I needed to tell you some details about anesthetic drugs and equipment to keep you aware of the seriousness of this procedure and to honor our dear anesthetists who are kept in shadows most of time.

Now I will try to brief out some dangers and risks of general anesthesia as it is my duty to inform you about everything you need to know about general anesthesia:

1- Cardiac rhythm disturbances:

We call that (arrhythmia) where patient's with endogenous cardiac diseases or those with susceptible weak hearts could suffer some forms of disturbances of their cardiac rhythms. Atrial fibrillation, severe tachycardia, bradycardia, and even complete asystole (the heart stopped beating) are all side effects that could occur due to anesthetic drugs and techniques. 

2- Sudden drop of blood pressure:

Many anesthetic drugs could lead to depression of patient's blood pressure and hence the need for administering opposing drugs and fluids that will maintain the normal blood pressure of the patient.

3- Allergy to any kind of drugs administered:

Any patient could have any kind of allergy to any drugs that wasn't administered to him before. You don't know until you get it but don't worry, most of these reactions are mild and your anesthetist will immediately deal with it with some antidotes.

4- Sore throat and dry cough:

Due to introducing you with this awful endotracheal tube I told you about.

5- Bleeding:

Spinal anesthesia lowers bleeding risk in comparison to general anesthesia especial in caeserian section deliveries, that's why we would advice regional over general anesthesia whenever applicant and when regional anesthesia itself isn't posing some relative higher risk to the patient.

6- Post-operative pain:

Due to lack of proper analgesic technique and the nature of your wound itself and again that's why we recommend regional anesthesia because of post operative analgesic effect that could last for some hours after surgery.

7- Post-operative nausea and vomiting:

Mostly due to opioids use, they are good analgesics but the might increase the risk of vomiting post-operatively.

8- Difficulty of breathing:

Due to lack of proper recovery from the muscle relaxants we mentioned previously, also due to the nature of surgery itself as some surgeries will operate on abdominal or thoracic regions which might affect the quality and efficiency of respiratory muscles.

To wrap things up:

I tried to fully explain the true nature of anesthetists job and the nature and risk of general anesthesia. It is not like a button you push to sleep and push again to wake up. It is far more sophisticated and complicated than this which requires a highly skilled personnel to perform this procedure upon you to keep you safe and in good health.

My personal advice for you is to tell you medical history honestly to your anesthetist, tell him your concerns and he will keep your secrets and keep you safe. Get a full list of any prescriptions and drugs you take on regular bases and any reports for current or previous medical conditions. Don't forget to fulfill your fasting period (6-8) hours in adults and if possible try to quit smoking 2-3 weeks before surgery. Stay safe and in good health and we wish you all luck and happiness in life.

If you like this article, I have wrote previously another article about spinal anesthesia, check it out in this link.

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