How Anesthesia Works

If you are faced with the possibility of needing surgery in the

future, chances are you will need some type of anesthesia
to go along with it. There are many different types of
anesthesia. Which one you will need depends on a variety
of factors such as the type of surgery you are having and
your state of health. Some surgical procedures require only
an injection of local anesthesia into the incision area. Other

Definitions
Consciousness is being
clearly aware of yourself and
your environment.
Unconsciousness is when
you are completely or partially
unaware of yourself and your
environment, or you don't
respond to sensory stimuli.
Conscious sedation is
caused when an anesthesiologist
administers depressant drugs
and/or analgesics in addition to
anesthesia during surgery.
Consciousness is depressed and
you may fall asleep, but are not
unconscious.
Sleep is a state of reduced
consciousness, depressed
metabolism, and little activity of
the skeletal muscles. Strong
stimuli such as loud noise, bright
light or shaking can arouse the
sleeper.
procedures cannot be
performed unless you are
completely anesthetized --
unconscious and unaware of
pain. Your anesthesiologist will
tell you which type of anesthesia
you need.
In this article, we will look at the
many types of anesthesia so
that you can understand what it
is, how it works, and how the
anesthesiologist determines
which type of anesthesia to use
for your particular situation. By
addressing this topic, we hope
that you will have a better
understanding of what happens
to you while you're anesthetized
and perhaps make the process
a little less mysterious.

The Basics
Anesthesia is divided into four basic categories:

• general anesthesia
• regional anesthesia
• local anesthesia
• sedation

Each type of anesthesia has an effect on a part of the nervous system, which results in a
depression or numbing of nerve pathways. General anesthesia affects the brain cells, which
causes you to lose consciousness. Regional anesthesia has an effect on a large bundle of
nerves to a particular area of the body, which results in losing sensation to that area without
affecting your level of consciousness. Local anesthesia causes you to lose sensation in a
very specific area.
Some of the drugs that produce general anesthesia in large doses can be used to produce
sedation, or "twilight sleep" in lower doses. Sedation can be given in many ways. A common
example of an anesthetic gas that is used for sedation is nitrous oxide or laughing gas.

If you are scheduled to have surgery, you may be told not to eat anything for eight hours. It is
very important that you follow whatever instructions you are given for not eating or drinking
anything prior to surgery. Why? Because when you are given anesthesia, you lose the ability
to protect your lungs from inhaling something you're not supposed to inhale. When you are
awake, you can usually swallow saliva and food without choking because part of the
swallowing mechanism involves a reflex that results in covering the opening into the lungs.
When you are anesthetized, you lose that reflex. So, if you have any solids or liquids in your
stomach, they could come up into your mouth and be inhaled into your lungs. The result
could be very serious lung damage.

General Anesthesia
General anesthetics produce an unconscious state. In this state a person is:

• unaware of what is happening

• pain-free
• immobile
• free from any memory of the period of time during which he or she is anesthetized

It is not completely clear exactly how general anesthetics work at a cellular level, but it is
speculated that general anesthetics affect the spinal cord (resulting in immobility), the brain-
stem reticular activating system (resulting in unconsciousness) and the cerebral cortex (seen
as changes in electrical activity on an electroencephalogram).

Photo courtesy Department of Defense: Defense Visual Information Center

Lt. Brenda Shealy checks a piece of anesthesia equipment in
an operating room during Operation Desert Shield.

General anesthesia can be administered as an inhaled gas or as an injected liquid. There

are several drugs and gases that can be combined or used alone to produce general
anesthesia. The potency of a given anesthetic is measured as minimum alveolar
concentration (MAC). This term describes the potency of anesthetic gases. (Aveolar is the
area in the lung where gases enter and exit the bloodstream via the capillary system).
Technically, MAC is the alveolar partial pressure of a gas at which 50 percent of humans will
not move to a painful stimulus (e.g. skin incision). Injected liquid anesthetics have a "MAC
equivalent" which is the blood concentration of the liquid anesthetic that provides the same
effect. Using MAC as a guideline, the amount of anesthetic given to a patient depends on
that particular patient's needs.

When anesthetics reach the bloodstream, the drugs that affect the brain pass through other
blood vessels and organs so they are often affected too. Therefore, patients must be
carefully monitored. The anesthesiologist continuously monitors the patient's heart rate,
heart rhythm, blood pressure, respiratory rate, and oxygen saturation. Some patients may
have even more extensive monitoring depending on their health and which type of procedure
or surgery they are having.

Most adults are first anesthetized with liquid intravenous anesthetics followed by anesthetic
gases after they are asleep. Children, however, may not like having an injection or
intravenous catheter placed in them while they are awake. Therefore, they often breathe
themselves to sleep with anesthetic gases given through a mask.

Inhaled Anesthetics
Many adults may remember having ether for their anesthetic when they were young. Ether is
an inflammable anesthetic that is no longer used in the United States. Today, the commonly
used inhaled anesthetics are nitrous oxide (also known as laughing gas), sevoflurane,
desflurane, isoflurane and halothane.

Why do we have so many different kinds of gases? Because each gas has its own special
properties. For example, sevoflurane and halothane are easy to inhale while desflurane is
very irritating to inhale and has a shorter duration of action. If you need to breathe yourself to
sleep, halothane or sevoflurane would be easiest to inhale. If a very short-acting anesthetic
is needed, the anesthesiologist can switch to desflurane after you fall asleep. Nitrous oxide is
easy to inhale, but when used alone is not potent enough to be a complete general
anesthetic. However, it can be used alone for sedation, or combined with one of the other
inhaled anesthetics or injected liquid anesthetics for general anesthesia.

These gases have different effects on other organs as well. For example, halothane may
cause the heart rate to slow down and the blood pressure to decrease while desflurane may
cause the heart rate to speed up and the blood pressure to increase. How do these inhaled
anesthetics reach the brain? When an anesthetic gas is inhaled into the lungs, the blood that
travels through the lungs carries the anesthetic gas to central nervous system cells. The rate
at which the bloodstream takes up the anesthetic is dependent on many factors including the
concentration of the inspired gas, the rate of flow of the gas from the anesthesia machine,
the solubility of the gas in blood, the rate and depth of breathing, and the amount of blood
the heart pumps each minute in the person breathing the gas.

An important property of anesthetics is reversibility. When the surgery is over, the

anesthesiologist wants to shut off the anesthetic and have the patient wake up from the
anesthetic-induced sleep. Once the anesthetic gas is turned off, the blood stream brings the
gas back to the lungs where it is eliminated. The more soluble the gas is in blood, the longer
it takes to eliminate. Nitrous oxide and desflurane are the shortest-acting anesthetic gases
because they are the least soluble in blood.
Injected Anesthetics
A liquid anesthetic drug is delivered to the brain by injecting it directly into the bloodstream,
usually through an intravenous catheter. Examples of injected drugs are barbiturates,
propofol, ketamine, and etomidate, as well as larger doses of narcotics (such as
morphine) and benzodiazepines (Valium-like drugs). These drugs quickly reach the brain
and their effect is dependent on several factors including the volume in which the drug is
distributed in the body, the fat-solubility of the drug, and how quickly the body eliminates the
drug.

A commonly used injected barbiturate anesthetic is sodium thiopental, also known as

Pentothal. This drug is fat-soluble and acts very quickly. If you receive sodium thiopental and
then you are asked to count backward from 100 after the drug is injected, you probably won't
remember counting past 95. Some injected anesthetics are used in low doses for sedation. A
small dose of a narcotic or a benzodiazepine like Valium or Versed can significantly decrease
anxiety. These drugs are used in these doses either as a premedication prior to general
anesthesia or as "twilight sleep" or sedation when used in conjunction with local or regional
anesthesia.

Regional Anesthesia
Regional anesthesia is so named because a "region" of the body is anesthetized without
making the person unconscious. One example of this is spinal anesthesia, which is often
used on women during childbirth. A local anesthetic is injected into the spinal fluid and
causes a loss of sensation of the lower body. Spinal anesthesia can be used for surgery on
the legs or lower abdomen (below the bellybutton).

Epidural anesthesia is similar to spinal anesthesia in that a patient loses sensation in the
legs and lower abdomen, but instead of injecting the local anesthetic into the spinal fluid, the
anesthetic is injected into a space outside the spinal canal called the epidural space. A small
tube or catheter can be placed into this space and a local anesthetic can be infused (fed)
through the tube for hours, days, or even weeks. This type of anesthesia can be used for
surgery with larger doses of anesthetic, or for chronic pain relief with lower doses of
anesthetic. Regional anesthesia techniques can be used to block very specific areas such as
one foot, one leg, one arm, or one side of the neck. In these cases, a smaller group of
nerves is blocked by injection of the local anesthetic into a specific area. For spinals and
epidurals, narcotic painkillers such as morphine and fentanyl can be used in addition to a
local anesthetic.

Local Anesthesia
Local anesthesia involves numbing a small area by injecting a local anesthetic under the skin
just where an incision is to be made. When used alone, this type of anesthesia has the least
number of risks. Local anesthetics are thought to block nerve impulses by decreasing the
permeability of nerve membranes to sodium ions. There are many different local anesthetics
that differ in absorption, toxicity, and duration of action.
 Photo courtesy Department of Defense: Defense Visual Information Center
Captain Cynthia Warwick (right) and Staff Sergeant Chad
Smith, U.S. Air Force, prepare a syringe with local anesthesia
during Operation Enduring Freedom.

One of the most commonly used local anesthetics is lidocaine (Xylocaine). Lidocaine can be
administered as an injection or placed topically on mucous membranes. Another topical
anesthetic is cocaine. Cocaine is primarily used to anesthetize the nasal passages for
surgical procedures. A topical anesthetic that is gaining popularity for anesthetizing the skin
prior to painful procedures, such as injections, is known as eutectic mixture of local
anesthetics (EMLA) cream which contains lidocaine and prilocaine. This white cream is
placed on the skin and then covered with an occlusive dressing for approximately one hour
to obtain a good numbing effect. In addition, EMLA can be used to numb the skin prior to
giving injections or pulling superficial splinters.

Sedation
Some of the drugs that produce general anesthesia in large doses can be used to produce
sedation or "twilight sleep" in lower doses. Sedation can be given in many ways. A common
example of an anesthetic gas that is used for sedation is nitrous oxide or laughing gas.
Liquid sedating drugs are usually given by injection but some can also be given by mouth.
Ketamine and Versed are examples of sedating drugs that can be given by injection or by
mouth. The oral route is particularly useful for sedating children who do not like injections.

Children who refuse to drink medications may also receive sedation through the rectum via a
small, lubricated tube or via the nasal route by spraying it into the nose. Regional and local
anesthesia can be combined with sedation to make patients more comfortable during a
procedure in which general anesthesia is not necessary, or when general anesthesia may be
too large a risk for the patient.

The Anesthesiologist
To become an anesthesiologist, a person must complete college, medical school, an
internship and a three-year anesthesiology residency (see How Becoming a Doctor Works).
An anesthesiologist is a physician who specializes in anesthetic administration, pain relief,
and the care of patients before, during, and after surgery. The anesthesiologist monitors vital
organ functions including heart rate, blood pressure, breathing, and blood-oxygen saturation
during surgery.

Photo courtesy Department of Defense: Defense Visual Information Center

The are various monitors on an anesthesia machine.

Prior to the day of surgery, you may meet your anesthesiologist. Most of the time, you meet
on the day of surgery. Your anesthesiologist may ask several questions about your medical
history. This information is important in determining which type of anesthesia you should
receive. Your anesthesiologist can answer any questions you have about the side effects
caused by anesthesia. Children receive the same anesthetics for surgery as adults, but the
doses of the injected anesthetics are determined by the child's weight.

My patients are often small children who are not happy about seeing a doctor. Their parents
or guardians are usually very anxious about the anesthesia. A large part of my job before
surgery is explaining the anesthetic plan and reassuring the parents or guardians by
answering questions about what is about to happen to their child. Children may be given the
sedative, midazolon, before they are anesthetized. This is often in the form of a cherry-
flavored drink. After about 10 minutes, the children are smiling and don't mind coming to the
operating room with one of their parents or guardians. They usually don't remember it either.
In the operating room, the child receives the anesthetic either by breathing a gas through a
mask or by an injection. After the child is asleep, the parents or guardians leave and the
child's safety is in the anesthesiologist's hands.

While the child is anesthetized, blood pressure is closely monitored with a blood pressure
cuff, the heart rate and rhythm with an electrocardiogram (also known as an EKG), the
child's breathing, temperature, and the saturation of oxygen in the blood with a special
machine called a pulse oximeter. These vital signs are used to help determine the depth of
anesthesia. In addition, there is a monitor that can measure the depth of anesthesia using
brain waves. However, the most important part of the monitoring is done by the
anesthesiologist watching the patient.
After the surgery, the patient goes to the recovery room for constant monitoring until he or
she awakens. Then the patient is ready to be discharged from the recovery room. The doctor
assigns the patient to a hospital bed or discharges the patient if it is outpatient surgery.
Sometimes, the patient goes to an intensive care unit after surgery. Anesthesiologists, who
specialize in intensive care, often take care of patients in the intensive care unit as well.