The ABCs of Anesthesia: A Primer for Managers

Alan P. Marco, MD, MMM, FACPE, Medical College of Ohio

Not long ago, general anesthesia with inhalational agents was the prevailing practice for most surgery. Today, thanks to advances in technology and pharmacology, we can tailor the anesthetic regimen to the procedure, patient, surgeon, setting, and anesthesia provider. While this capability has helped ensure rapid recovery and enabled many procedures to ?go outpatient,' it has also added complexity to anesthesia practice. Anesthesia today is a lot like meatloaf: Everyone swears by a different recipe, but one is not necessarily better than another.

In this article, I will review the three basic approaches to outpatient anesthesia-including local/regional anesthesia, sedation, and general anesthesia-and discuss the goals of outpatient anesthesia so you can better understand your providers' regimens and make informed anesthesia choices for your facility.

Local/Regional Anesthesia
For cases such as cataract removal, hernia repair, and other surgeries below the navel or involving the arm or shoulder, the anesthesia provider will often use local or regional anesthesia using lidocaine, bupivacaine, tetracaine, ropivacaine, or chloroprocaine. This technique is increasingly popular in the outpatient setting because, when compared with general anesthesia, it can minimize postoperative nausea and vomiting (PONV).

Techniques of local anesthesia administration include:

• Topical, or the administration of an analgesic topically to desensitize a small area for a short time.
• Infiltration, or the injection of a dilute solution directly into the affected area.
• Local nerve block, or the injection of a local anesthetic near nerve branches proximal to the affected area. This anesthetizes the nerve supplying the area.

Techniques of regional anesthesia include:

• Spinal, or injection of an anesthetic into the subarachnoid space of the spinal canal to block impulses along the spinal cord.
• Saddle block. A spinal anesthetic in which the drug and patient position during placement result mainly in anesthesia of the perineal area.
• Epidural. Injection of the anesthetic within the vertebral canal, but outside the dura, at any level. This is useful when the patient needs anesthesia for a long period because the provider can administer continuous or repeated doses of anesthetic through a catheter.
• Caudal block. An epidural administered in the sacral canal resulting in anesthesia to the perineum.

During local or regional anesthesia, the practitioner may also sedate the patient with an intravenous (IV) agent. In this case, sedation serves only to relieve patient anxiety and is typically minimal to moderate. However, sedation is not mandatory; the presence and level of sedation depend on the patient's needs and procedure length and intensity. For example, a relatively long and noxious procedure such as mastectomy performed under thoracic epidural anesthesia warrants moderate sedation, whereas a breast biopsy patient who does not mind being awake but feels anxious may be well served with an anxiolytic such as midazolam.

The provider may also add a narcotic (opioid) to the regimen during local or regional anesthesia. This can relieve discomfort caused by positioning, even if the anesthesia is working well.