Anaesthesia

In order to perform an operation or a diagnostic intervention, it is necessary to eliminate pain and, sometimes, conscience, too. It is the task of the anesthetic procedure that we recommend.

There are two different procedures:

The general anesthesia of the entire body orThe local or the regional anaesthesia of single body portionsThe performance of a planned or urgent surgical procedure and the preliminary discussion with the surgeon is preceded by a detailed informative consultation with your anesthesiologist, which is necessary for determining the type of anesthesia.

If you are treated on an inpatient basis, the discussion of premedication takes place on the day before the operation, except for the emergency cases. It can also take place a couple of days before the surgery as part of pre-admission surgery planning in our clinic.

You will receive the documents necessary for premedication from the surgical clinic. The main goal of the consultation is to give you information about different options of anesthesia and pain elimination for the planned operation, to make a comprehensive evaluation of your state of health including risk assessment and to create an atmosphere of confidence through getting to know each other personally.

As a rule, the consultation on premedication takes place in the anesthesia outpatient department or at your medical station. To prepare for the consultation in the best possible way, you should bring all copies of medical documentation available (medical reports, examinations by your private doctor or other specialists, allergy passport and so on) and a list of medication you take at the moment with appropriate dosage. It is also important to provide information about painkillers (e.g. diclofenac, ibuprofen, opioids) as well as about blood thinning medication (e.g. Marcumaror ASA) taken.

Before the consultation with an anesthesiologist, you will receive an anesthesia information sheet that you should read carefully and answer all the questions.

It is important to provide information about your previous diseases, especially these concerning the cardiovascular system, respiratory tracts, liver and kidney diseases, metabolic disorders, blood coagulation with increased bleeding tendency, neurologic deficits, nervous disorders, muscle diseases, allergies and drug intolerance. Please, let us know about all previous operations, performed under general or local anaesthesia. Do not forget to mention the problems occurred at that time and bad experiences you have made. If some incidents connected with narcosis are known in your family, please, state it as well.

Different types of anesthesia and their special, in part very rare risks are published on our homepage in an understandable way, as required by legislation. You will find a detailed presentation of it in the above-mentioned anesthesia information sheet.
In order to fulfill the task of a safe and pleasant care before, during and after the operation, the anesthesiologist will discuss with you the form of anaesthesia and will find the best solution. At the same time, advantages and risks of different kinds of anesthetics will be explained. If you still have any questions, you can ask them during the personal consultation, in order to avoid unnecessary anxiety and fear.

After discussing your findings and performing a physical examination, we shall be able to evaluate how high your individual risk might be. With diseases having an increased anesthetic risk, the anesthesiologist can perform some additional examinations, in order to prepare for the surgery in a better way.

After this preliminary examination (premedication), your anesthesiologist will advise you with consideration of your findings and determine the safest and the most pleasant form of anaesthesia together with you. You will also learn what benefits or risks different anesthesia methods have.

The type of anesthesia suitable for you depends on your general physical condition, the area of the operation and the surgical method. In addition, your personal wishes will be taken into consideration. Speak openly about your wishes and worries and ask us, if you do not understand something.

If the operation to be performed is associated with an increased risk of bleeding, the anesthesiologist will advise you to make autologous blood donation, independent from the type of anesthesia, if there are no severe previous illnesses, which could prevent it. By request, on the evening before surgery, you will receive an anti-anxiety medicine (a sedative), in order to sleep peacefully before the planned operation.

In order to avoid unnecessary risks, please observe following safety rules:

Please do not eat anything for 6 hours before the anaesthesia, do not even drink any milk! Before an anesthesia, your stomach should be empty.Please do not drink anything for 2 hours before the anesthesia! The only exception is taking the medicine, preparing you for the anesthesia, and your own important medicine with little water, if you have discussed it with the anesthesiologist. Until then, clear fluids are allowed (e.g. mineral water, juices without pulp, tea and coffee without milk, lemonade, etc.)Please do not smoke any more on the operation day!
Please do not use any make up on the operation day and do not paint your nails. Leave your contact lenses, removable tooth elements (dental prostheses), hearing aids, wigs as well as other prostheses in the ward.
Please take off all jewellery (e.g. earrings, necklaces, rings, piercings) and leave it in the ward.
Breast-feeding is allowed before the operation starts.
As a rule, on the day of operation and examination you will receive medicine with an effect, which is specifically adjusted, to your situation. This will be partially your own medicine that you take regularly. During the preliminary consultation, the anesthesiologist will tell you, which medication you should eventually take with a small sip of water in the morning of the operation day.

Secondly, shortly before surgery (about ½-1 hour before) you will get some medication, mostly in form of pills, that has a calming anti-anxiety effect. It will not only release your anxiety, but also reduce the stress factors, connected with it. The lower is the stress that a patient has, the better is way he tolerates anesthesia and the process of surgery.

When you enter the presurgical room, our anesthesia care team and anaesthesiologist will carry out some preparatory anesthesiology measures: they will carry out an electrocardiogram (ECG) and give you a blood pressure cuff and a finger clip for monitoring the level of oxygen in blood (pulse oximeter). Then a plastic cannula (“needle”) will be placed into one of the veins of your arm or at the back of your hand, which is followed by an injection (venous drops). Later, this cannula will be used for injecting the anesthetic. The further procedure can vary, depending on the type of anesthesia (general or regional).

I. General anesthesia
General anesthesia can completely switch off consciousness and pain sensation in the entire body.
The word “narcosis” has derived from Greek “narkos” and means sleep. From the beginning to the end, a patient is in a kind of a sleep-like state. He does not remember the surgery and unpleasant impressions, connected with it.

Today, in order to achieve this state, it is common practice to use a combination of medications, individually adjusted to you (narcotics and analgesics, medication for muscle relaxation and influencing the vegetative nervous system). The supply of medication is carried out either through inhaled air in the form of gases, or through the application of venous drops.

A facial mask, to provide you with more oxygen and to deliver an optimal amount of oxygen to your lungs and blood before you fall asleep, often supports anesthetic induction. Now you will sleep safely and peacefully and can be operated on without any pain. After you fall asleep, we shall support your breathing by means of this facial mask.

Short procedures (up to 15 minutes) can be easily performed with the help of this facial mask (mask anesthesia). Longer operations and diagnostic procedures require securing of the airways through inserting the tube into the throat (laryngeal mask) or trachea (endotracheal tube for the purpose of intubation). The artificial respiration with supply of oxygen and eventual gaseous anesthetics is carried out.
During the operation, the whole anesthesiology team will take care of eliminating pain, monitoring the vital body functions (cardiovascular system, respiratory system, etc.) and support their maintenance. The process of anesthesia will be controlled by the anesthesiologist with the help of medication and maintained during the entire operation.

With larger surgical interventions and severe previous diseases, it is sometimes necessary to carry out an advanced monitoring, in order to evaluate your state of health in a better way. Here we mean applying of additional vein indwelling cannulas for a better supply of fluids, a stomach tube for deriving the stomach secret and a bladder catheter for controlling of the urinary flow rate. From time to time, it is necessary to insert central venous catheters (CVC) into the prominent neck veins, the groin and below the collarbone for supplying with medication supporting blood circulation or for postoperative oral intake.

If a continuous blood pressure monitoring is indicated, arterial catheters are attached to the wrist or in the groin. With a few exceptions, these measures are carried out after the induction of anesthesia and are absolutely painless. During longer interventions, we shall actively protect you from cooling, using warm air.

Risks of general anesthesia
Our modern anesthesia methods are safer than ever. Even in case of emergency operations and with severely ill patients, serious complications occur much more seldom during and after general anesthesia. Similar to any other medical procedure, despite of regularly trained and professionally qualified medical staff, the latest medical technology and safe medication, there is still some low residual risk as a result of potentially inevitable risks. These risks are often indirectly connected with the surgery itself.

The most common complaints after anesthesia are skin irritations or small bruises in the area around the puncture mark of the indwelling vein cannulas or catheters, cold-like sore throat and some hoarseness after insertion of respiratory tube, which disappear within 1-2 days. In some rare cases, tooth and larynx damages may occur.
Even today, it is still possible that you experiencing nausea and vomiting after anesthesia. In a medical jargon, they are often called “the little big problem” and depend on the sex, weight, age and surgical method. In very rare cases, a transfer of stomach content into the lungs (so-called aspiration) with a following severe pneumonia can happen, because alongside eliminating pain, all the protective reflexes (e.g. cough reflex and swallowing reflex) are subdued.

Another important, but avoidable source of danger is connected with breaking preoperative restrictions (eating, drinking, smoking) 6 hours before the operation. The danger of aspiration depends on the fact, how long ago you have had you last meal and how large it was. Therefore, it is in your own interest to observe preoperative rules unconditionally. With all the other unavoidable sources of danger, such as overweight, pregnancy from the 12th week and preexisting gastrointestinal diseases and surgeries, it is usual to apply special anesthesia methods that avoid the transfer of the stomach content into the lungs (prevention of aspiration).

In very rare cases, especially with increased duration of the operation and despite of thorough and painstaking padding of all parts of the body, some damage may occur because of pressure on nerves. Within a few months, following sensory disturbances in the arms or legs and paralysis are usually reduced by themselves.

The incidents of anesthesia, resulting from drug or material intolerance that affects cardiovascular or respiratory systems, have become extremely rare. A severe anesthetic accident, characterized by derailment of muscle metabolism under anesthetic, so-called malignant hyperthermia, is an absolute exception. Patients facing risk of malignant hyperthermia either suffer from muscle disorders (muscle dystrophy) themselves, or there is this disease in the family.

With larger surgical interventions or increased anesthesiological risk, resulting from preexisting diseases, it is necessary to extend monitoring procedures. These include administrating a stomach tube, a bladder catheter, a central venous catheter, as well as the cannulation of an artery for continuous blood pressure measurement and much more. On request, the anesthesiologist will inform you about special risks of this procedure during the pre-operation discussion. Moreover, another topic of your discussion will be the risks of a possibly required allogeneic (not-from-patient) blood transfusion, including the opportunity to avoid using blood from a stranger.


II. Regional anesthesia
It is also possible to eliminate pain by means of partial anesthesia (regional anesthesia) through numbing of surgical area itself (local anesthesia) or of the related nerves belonging to the body region that should be operated on (conduction anesthesia).
Regional anesthesia can be divided into spinal and peripheral, applied to separate nerves, mostly of arms or legs.

During the operation, you will stay awake. However, you will not feel any pain, because the nerve brocade leads to a short interruption of pain transmission. Normally, partial anesthesia results in a temporary loss of control over the affected part of the body.

If the situation of being awake during the surgery is unbearable for you, we can give you a sedative on request, so that you fall asleep for a short time. We are also pleased to offer you listening to the music, for you to distract yourself.

Techniques applied close to the spinal cordSpinal techniques include spinal and peridural anesthesia. With both techniques, elimination of pain is achieved through the injection of a local anesthetic into the area close to the spinal cord, which follows the thorough skin disinfection, covering with sterile cloths and local numbing of the puncture and puncture channel between the vertebral bodies. This way, pain transmission between ends of nerves in the surgical area and the brain on switching points of the spinal cord is blocked.

Spinal anesthesia
In case of shorter operations, spinal anesthesia can be performed in the area below the navel (lower abdomen, pelvic area, legs). During the procedure, a small amount of anesthetic will be injected with the help of a thin, extremely fine needle into the dural sac in the area of the lumbar spine below the spinal cord, in which spinal cord nerve roots swim freely in the fluid (so-called liquor cerebrospinalis). The needle will be removed after the injection. The puncture will be covered with a band-aid.

One can observe a rapid onset of effect after 5 minutes already, due to the fact that anesthetic directly influences the nerve roots of the spinal cord, situated above the injection port. The first thing you notice will be a strong sensation of warmth in your legs. Soon after that, you will be only able to move them a little or will not be able at all.

Pain will be eliminated for about 2 hours or longer. Furthermore, functioning of bladder and bowel, as well as power of legs can still be restricted for several hours. Spinal anesthesia is considered a very safe procedure. D not worry about the fact that sensation in your legs returns a couple of hours later.

Peridural anesthesia
During peridural, or epidural, anesthesia, a local anesthetic will be injected through a thin tube into the area between the vertebral body and the dural sac, filled with fatty tissue.

One can observe a slower onset of action, if compared to spinal anesthesia. The effect can be expected after about 5-15 minutes. The reason is that a local anesthetic needs time to cover the area from the catheter up to the nerve roots surrounding it. At the beginning, you will also feel some sensation of warmth, followed by losing moving force in the legs.

This procedure has an advantage that it can be either used alone as a pain elimination method, or in a combination with general anesthesia (as so-called combined anesthesia), as well as in long-term postoperative pain therapy. It is appropriate for all kinds of operations on the trunk of the body below the collarbone (chest, abdomen and pelvis) and on the limbs.

CSE
In the meantime, a combined spinal and epidural anesthesia (so-called CSE), used for fast and long-lasting pain elimination has been applied during surgieries.

If the anesthetic technique, applied close to the spinal cord, is not effective enough, it is sometimes necessary to go over to general anesthesia, in order to ensure a painless intervention. For this reason, you will be additionally informed about general anesthesia during the preoperative discussion. While planning regional anesthesia, please pay attention that it is very important to observe fasting rules

Risks of spinal and peridural anesthesia
The techniques, applied close to the spinal cord, are considered very secure today, so that complications resulting from anesthesia occur, all in all, extremely rare. However, there is still a low residual risk, similar as in the case of general anesthesia.

Temporary disturbances of bladder emptying belong to the typical problems of the both procedures, thus, requiring a transient administration of a bladder catheter. Slight circulation disorders, such as a slowed pulse and drops in blood pressure, can be immediately healed. Sometimes, there can be a strong headache as a result of a anesthesia, applied to the spinal cord, which requires treatment in order to eliminate complaints. The headache should not necessarily depend on the performance of regional anesthesia, especially, if headaches (e.g. migraine) have already been a common thing in the medical history.

Severe incidents, involving cardiovascular system or respiratory tracts, are extremely rare. Possible causes include an accidental insertion of a local anesthetic into a blood vessel, or drug intolerance. Meningitis, deterioration of eyesight and hearing and remaining paralysis up to paraplegia, resulting from effusions of blood, infections or nerve damages, are also extremely rare.In order to avoid such extreme and serious complications, you should check your legs for sensory dysfunctions 6 hours after the end of the surgery. If some numbness, pain or motor weakness in the leg area occurs later, you should immediately inform your treating physician about it and ask for pain elimination in the spinal area. You should bear in mind that the time factor plays a decisive role in prevention of worse consequences.

Blockade of separate nerves – peripheral nerve blocks
During peripheral procedures, separate nerves or so-called nerve plexuses are blocked within the whole area of the body region that should be operated on up to the central nervous system. It causes a temporary interruption of the information transmission, especially of the pain, to the brain. At the same time, in the opposite direction, the command given by the brain to activate the muscles will be interrupted for the same period of time.

After thorough skin disinfection, covering with sterile cloths and local numbing of the puncture and puncture channel, a very thin injection needle is inserted into the respective anatomical region.

If the operation is performed in the area of the arms, hands or shoulders, the transmission of pain will be interrupted in the armpit, below the collarbone or in the lower neck region. All the nerves of the spinal column are accumulated there, bundled in a nerve sheath, the so-called brachial plexus. That is why this form of anesthesia is also called brachial plexus anesthesia. In these areas, the plexus can be temporarily numbed through administration of a local anesthetic.

In the region of legs, it is possible to perform such a peripheral elimination of pain in the groin area or along the separate nerves of the legs, similar to arms. A frequently used procedure is, for example, a femoral nerve blockade for interventions on the hip.

In order to define the exact spot, your anesthesiologist will apply a nerve stimulator. It is a device that transmits very weak electric impulses of 0,1 mA and is connected with an injection needle. The current impulses cause an automatic twitching of the muscles which nerves should be numbed. This way your anesthesiologist can identify the proper position of the injection needle. Now a local anesthetic can be injected into this area.
It takes about 15-20 minutes for anesthetic to start working. After that, the numbed body region is warm and insensitive. For several hours, you cannot move your arm or can just move it to a certain extent. A great number of nerve blockades can also be performed to achieve a short-term numbness of separate nerves in the arm area. For a long-term elimination of pain after surgical interventions in the area of arms and legs that are known to be very painful, it is also possible by means of this method to administer pain catheters, which allow a continuous administration of pain relievers and ensure pain relief for a number of days.

Risks of peripheral techniques
Peripheral nerve blockades are considered very secure today, so that the complications resulting from anaesthesia can be all in all ranked as extremely low. However, there is still some (low) residual risk, as in the case of general anaesthesia.Typical, but infrequent risks include inflammations, effusions of blood and secondary hemorrhages at all the punctures and puncture channels left from cannulas and catheters, incompatibility reactions (allergies) to medication and materials used, as well as nerve and vessel injuries.

What happens in the recovery room?
After a successful surgery, you or your child will be placed into the recovery room for a postoperative care. Our team of recovery room has an aim to monitor and stabilise all the vital body functions.

Unpleasant symptoms that can occur after the operation, as for example, pain, nausea or shivering will be treated there. As a rule, after you leave the recovery room, you will be sent to the normal ward after 30-60 minutes. In case you have had regional anesthesia, you can go back to your ward immediately as a rule. There you can eat and drink again.

What is the task of a postoperative pain care service?
Strong postoperative pains can impair your healing process after the surgery. The pains after a larger abdominal operation can, for example, impair deep breathing; the pains after orthopedic interventions on the legs can prevent you from standing up for a short period. During and after the surgery, you will be given some highly effective analgesics, for you not to get into such an unpleasant situation. The pain therapy will be started in the recovery room already.

When you return to your ward, this task will be taken over by the staff of this ward, who will receive a corresponding recommendation from your anesthesiologist in a written from. These recommendations include not only analgesics, but also the way it is administered (e.g. in form of tablets etc.). If you feel any pain, please inform the care staff about it immediately. In some special situations (e.g. after major operations), pain therapy will be carried out in the ward all around the clock. You will be regularly visited by the staff of our acute pain service, whose task is to make sure that you feel possibly no or very little pain.

In order to evaluate the intensity of pain, we will ask you to classify your perceptions according to the numerical scale between “0” (no pain) and “10” (“maximum imaginable” pain). It makes the qualitative assessment of the conducted pain treatment much easier. We will increase your satisfaction through the fine adjustment of different methods available.

It is possible to achieve an effective pain therapy through numerous procedures. These include administration of pain pumps (PCA = patient-controlled analgesia), programmed specially for you, or a continuous regional elimination of pain through the pain catheter at the spinal cord of the spinal column (PDA) or at the peripheral nerves.

PCA pumps
The method of patient-controlled analgesia (PCA) enables you to get a dose of analgesic, individually adjusted to you, which is administered via a computerised pain pump, connected through a tube with a vein indwelling cannula or through a central vein catheter with your circuit.

A couple of minutes later it can be requested again, in order to combat the emerging pain directly. This way, you take your pain therapy into your own hands. It is a very safe method, because after the administration of analgesic the device is blocked for some time, in order to avoid overdosage because of too frequent requests. It is important that you press the button only in case you have pains. You should not take in the medication, just in order to fight your inner restlessness.

Pain treatment by a catheter method
Another method of a postoperative pain treatment is a continuous regional elimination of pain through central or peripheral pain catheters (catheters close to the spinal cord, plexus catheters). After applying a thin tube near the affected pain fibres, the continuous administration of analgesic via the pain pump can be carried out.

An essential advantage of this method is that its effect is localised in the pain area only. This way unpleasant side effect (nausea, tiredness) of an intravenously administered analgesic can be avoided. However, the catheter method cannot be applied everywhere. Due to connection with our pain care centre that has a large pain outpatient department and a possibility of providing an inpatient treatment, we can offer our patients who experience pain over a longer period, for example, tumour patients, a number of concepts for a long-lasting pain relief
 
Postoperative intensive therapy
Complex, extensive and long-lasting surgical interventions, as well as severe preexisting diseases, make intensive medical care necessary for some of the patients. Our interdisciplinary intensive care unit allows providing a continuous monitoring, further maintenance and restoration of disturbed organ functions, so that difficult operations can be carried out in our clinic without an increased risk.

You will experience intensive care through a continuous presence of our trained care staff and highly qualified specialists for intensive medicine. This intensive care is also characterised by an enormously high technical effort. Do not get worried or annoyed with numerous devices with various alarm tones. Not every alarm means something bad. All safety measures, well adjusted to your situation, are used only for the purpose of your own protection, so that we shall be able to intervene promptly in case of emergency. In intensive care, we are also trying to see you as a person and not to see your disease only.

Some surgical and diagnostic procedures can be performed on an outpatient basis. An outtpatient anesthesia does not differ essentially from anesthesia performed as part of an inpatient stay. However, outpatient treatment is characterized by some peculiarities you should be aware of, since you go back home on the day of the operation. During the preliminary consultation, you will be explicitly informed about the specific rules of conduct. Subsequently, the most important points will be mentioned once again.

Please observe the fasting rules; otherwise, it can possibly result in an unnecessary delay of your surgery. Further details can be found in the chapter “General rules of conduct on the operation day”. You should also inform the staff of our admission ward about short-term changes in your state of health (e.g. a bad cold).

On the operation day please be on time for your admission appointment in the ward, we have agreed upon together. Do not be angry, if you still have to wait after the admission. Unfortunately, from time to time our patients have to accept waiting times, because it is impossible to plan the duration of an operation exactly. Please bring along all missing documents (e.g. pulmonary function test, ECG etc.) and your insurance card on the operation day. Please do not use any make up or nail polish on the operation day. Leave your removable jewellery and contact lenses at home. Please do not bring your dentures and spectacles into the surgery room either.

After the surgery, you will be first sent to our recovery room and from there to the normal ward. You will stay there until you can be discharged from the hospital. As a rule, it happens within 6 hours. When anesthesia has ended, you will be monitored, in order to exclude undesirable after-effects. Sometimes, for various reasons, it is necessary for your own safety that you stay in the inpatient department after the surgery or anesthesia. We kindly ask you to understand that these measures are in your own interest and not be worried.

Upon your discharge, you are allowed to leave the clinic with a companion. It is also essential that you stay under continuous supervision and control of an adult during the first 24 hours after the end of anesthesia. The reason is the medication, administered for anaesthesia, which can restrict capacity of reaction. There should be a telephone at the place you stay. During this time you are not allowed to take an active part in road traffic (e.g. as a driver), operate machines (e.g. bread cutting machine) or sign contracts. From a legal point of view, you are not contractually capable at this time. You are not allowed to drink any alcohol during this time. Please take in your analgesics or other medication only the way and in dosage you have agreed upon with your physician.

It is not a problem to perform anesthesia on an outpatient basis, if you stick to these rules of conduct. If, however, some problems occur at home (fever of over 38,5°C, intolerable pain, severe nausea and vomiting etc.), you should call us. You can reach us around the clock at +49 (0)30 / 36501-0 and ask for a conversation with an anesthesiologist on duty.