Surgery has become a common procedure for relief of medical problems. Gone are the days when operation was a dreaded procedure with a high mortality (death) and complication rates. I tell my apprehensive patients that there are more accidents and resultant deaths on the roads ofChandigarhthan in all the operation theatres of Tricity and this comparison seems to give lot of confidence and solace to patients and their worried relations.
Surgical procedures have not only become safer but they are relatively pain free also, particularly if one compares them with the past experience. Major credit for this not only goes to better surgical techniques but also to safe anaesthesia and quick recovery from its after effects.
The type of anesthesia a patient receives depends on the procedure being performed, the physical and emotional status of the patient and also on the preference by the surgeon.
Anaesthesia can be administered mainly by three techniques
- General or total anaesthesia in which the patient as a whole is put to sleep
- Regional anaesthesia in which the region to be operated upon is blocked to sensations – epidural, spinal and caudal anaesthesia are the common examples of this
- Local anaesthesia in which only the operation site is anaesthetised facilitating pain free surgical procedure.
We shall be considering the last, the local anaesthesia, in detail. Number of techniques are available for giving local anaesthesia.
- by infiltration of a chemical agent in the concerned area, which produces loss of sensations and operation can be undertaken without causing discomfort to the patient. The commonest drug used is Lidocaine in injection form, can be diluted and used in the strength of 0.5 to 2.0 %, the effect lasts for about 30 to 45 minutes. Addition of Adrenaline prolongs its effective time for 60 to 70 minutes; and addition of Hyalurinase extends its area of effectiveness. Newer drugs like Etidocaine in concentration of 8mg \ Kg with Adrenaline can provide satisfactory local anaesthesia for 120 to 180 minutes.
- Ring Block – local anaesthetic agent is used in the form of a circumferential ring so that the sensations below the block are blunted. This form of anaesthesia is commonly used for fingers, although previously I have seen it being used for a limb also.
- Blockage of nerve– either for surgical procedure or to relieve excruciating pain in an area where other methods have failed- common examples being blockage of trigeminal ganglion in the face, coeliac axis block in the abdomen
- Tumescent techniques – in this larger amounts of anesthetic drug is used in dilute concentrations (0.05-0.1%) with Adrenaline (1:1,000,000). The anesthetic concentration is extremely small, allowing large amounts of solution to be used without reaching toxic levels and therefore it is quite safe.
The patient remains completely alert during local and regional anaesthesia. Addition of sedation either in mild or moderate doses not only potenciates the effect of local anaesthetic agent but also induces sleep \ drowsiness in the patient, the effect is beneficial not only for the patient but for the operating surgeon also.
The usefulness of local anaesthesia has been known for a long time but its versatility has been appreciated recently because of popularity of Day Care surgical procedures, the financial implications, suitability in relatively poor risk and elderly patients where general anaesthesia would be more risky. The non availability of a competent anaesthetist , sophisticated anaesthesia equipment and absence of proper post operative monitoring of a surgical patient have forced many surgeons to utilise local anaesthesia more frequently. It is good to have a standby anaesthetist but the surgeon himself can learn and administer local anaesthesia easily.
I shall like to share my recent experience with two of my patients who had undergone major operations under local anaesthesia as the anaesthetist did not find them suitable for general or regional anaesthesia and they could not be left without operations.
A lady of 55 years of age was found to have cancer of breast along with encephalitis resulting in marked impaired neurological functions. Operation was started with an aim to excise the tumour under local anaesthesia, but as the surgical procedure proceeded we could undertake total excision of the breast along with clearance of the axilla, the operation that she really required. She made an uneventful recovery, was given additional appropriate treatment for breast cancer and she rewarded us with complete recovery from her neurological problems and two years have passed and she is disease free.
A lady teacher of 65 years of age, belonging toGuwahati,Assam, had recurrent attacks of severe pain in her abdomen for the last five years because of large number of stones in her gall bladder. She has been suffering from Bronchial Asthma for the last 30 years, incapacitating her for any physical activity. Investigations revealed her lungs functioning only at 20% level and she was denied surgery in her home and neighbouring states also. Her brother, a senior plastic surgeon by profession, wanted some relief from recurrent attacks of excruciating abdominal pain. General or regional anaesthesia were considered to be too risky, surgery was started with local anaesthesia with mild sedation and our efforts were rewarded when we could complete the operation – removing the large sized gall bladder packed with multiple stones. We were pleasantly surprised to find the patient walking to the wash room just six hours after her surgery and she boarded the train 48 hours later for Guwahati, it is more than four months and she is much better than what she was before surgery. Chest physiotherapy and counseling have played an important role in her recovery.
Local anesthetics, used properly, are safe and have few major side effects but in high doses they can have toxic effects because of their absorbtion. This may have effects on breathing, heartbeat,blood pressure, and other body functions but are seen quite infrequently.
The take home message – people usually are very reluctant to divert from a well established routine procedure and try a new one but unless one practices it, one will never realise its value or develop expertise in it.