Fortunately most instances are short lived, lasting only briefly in the Recovery Room. Some last longer and require combinations of anti-nausea medicines. Rarely a patient will need to be admitted to the hospital longer than originally planned for nausea treatment and re-hydration.

It is also fortunate that the newer anesthetic agents, in conjunction with active research into the problem by anesthesiologists worldwide, have given us new tools and insights into the best strategies for prevention and treatment of PONV. The physicians of OAG are using a Continuous Quality Improvement model to analyze and deal with the problem. Please feel free to speak openly with your anesthesiologist about your concerns and how he or she will try to prevent or treat PONV for your surgery.

The biggest single step in preventing this complication is making sure patients have empty stomachs before beginning an anesthetic. The long-standing standard was to have adults and older children fast for 8 full hours before an operation. This period generally ensures an empty stomach and does not risk dehydration.

Newer research has shown that, in people with normal stomach functions, clear liquids readily pass through the stomach within two to three hours and, according to some studies, may lower the acid content compared to a strict fast. Along with this has come a realization that normal patients empty their stomachs of solids within six hours.

We at OAG have embraced this newer practice as an aid to patient comfort and a likely improvement in patient safety. Problems remain with trying to make these changes universal: The usual minor snafus in running an O.R. schedule make exact timing impossible. The liberalized guidelines don't apply to moderate numbers of our patients who have conditions that are known to delay stomach emptying: diabetics, those with ulcer disease, the obese, and the traumatized, among others.

Obviously, in emergent and urgent situations we cannot wait for the stomach to empty normally. In these cases we have precautionary measures that are very good at preventing the Aspiration Pneumonitis syndrome.

We don't always give "full general anesthesia," though. Many operations are handled best with a nerve block, a spinal, an epidural or a local anesthetic. Along with these we often give intra-venous sedatives. Some patients will report having pleasant dream-like experiences with these medications.

Most instances of recall occur in people with massive hemorrhage having emergency life-saving surgery. Such patients cannot tolerate normal anesthetics; they would depress already stressed vital functions even further and could hasten death. Such patients get resuscitation first, anesthesia second. Studies have shown that about 10 - 15% of survivors of these episodes will have some recall of the events.

The only time these drugs are used without general anesthetics is in the resuscitation of patients near death from certain types of shock. The anesthetic drugs might hasten death in these cases. Fortunately, most survivors of these resuscitations were so sick during the events that their brains recorded none of it and for all intents and purposes, "they weren't there."

Most patients prefer to be asleep during their own operations. If a Regional Anesthetic is the best choice for you during your specific operation your anesthesiologist can probably give you sedatives during the procedure so you can sleep through it. Of course this is not always possible. Feel free to discuss your concerns and desires with your anesthesiologist before your operation.

A rare genetic mutation makes some individuals susceptible to MH. When these MH-susceptible (MHS) people are exposed to certain anesthetic drugs an MH episode sometimes "triggers." The genetic defect, in conjunction with the triggering drugs, makes muscle cells unable to relax normally. This spastic contraction causes the cells to use up all available energy stores, run short of oxygen, and produce excessive waste products, including heat. Eventually some of the cells die.

The body's initial response to this stress is high blood pressure, high heart rate, and rapid breathing. The stress response, however, soon becomes exhausted and shock follows. Cardio-vascular collapse and death result if left untreated.

Fortunately there is a drug, dantrolene, which can reverse the process where it starts, at the level of the muscle cells. If given soon enough and in sufficient quantity, the muscle cells can relax and the cascade of derangement will reverse. MH had been 80 - 100% fatal before dantrolene; with dantrolene this figure has been brought down to 5 - 10%.

For more information please see the web site of the Malignant Hyperthermia Association of the United States (MHAUS).

Much more commonly people have non-allergic side effects and reactions such as blood pressure changes, nausea and vomiting, etc. Our entire focus of practice in anesthesiology is aimed at preventing these, (once we have ensured the patient's complete safety.)

On the mechanical side, though, every patient has, while under our care, a continuous EKG, a blood pressure measurement every few minutes, and a "pulse oximeter." A pulse oximeter is a small electronic device (brought to widespread clinical use in the early 1980's by two anesthesiologists) that gives a continuous readout of the patient's oxygen saturation. Since the biggest single source of disasters under anesthesia had been inadequate oxygen delivery (for a wide variety of reasons) the ability to monitor the oxygen delivery where it counts the most, in the patient's bloodstream, has been a major improvement in patient safety.

Patients receiving general anesthesia also have continuous monitoring of oxygen in the breathing circuit and their carbon dioxide elimination.

There is a wide array of additional monitors -- body temperature, indwelling lines that measure blood pressures in the arterial tree, in the venous inflow to the heart, in the pulmonary artery; continuous EEG; nerve stimulators, Doppler-effect blood flow monitors, trans-esophageal echocardiograms -- that may be used in specific instances depending on the operation and the patient's underlying health status.

Much bigger determinants of "feeling normal" will be how much or how little pain you have from the operation and what you need to take for it.

Though it has not been well quantified, most informed sources put the risk today at well less than half of what it was. Of note, 8.1% of the patients in the Welsh study received anesthetics that have not been used in the US in at least 15 years. Additionally, we get newer, better drugs all the time. Combined with the advent of pulse oximetry and carbon dioxide monitoring, and better training of personnel we believe the risk of dying today is closer to one in 50,000.

Most cases of permanent brain injury in the past resulted from lack of adequate oxygen delivery. This risk has been dramatically reduced in the past 15 years with the widespread use of pulse oximetry and carbon dioxide monitors, both OAG standards of routine care.

The physicians at OAG take every complication seriously and are constantly working to improve patient safety and comfort. If you have specific concerns about your situation please feel free to discuss them with your anesthesia physician before or after the anesthetic.

We have gotten away from the old practice of requiring day-surgery patients to drink and retain (i.e., not vomit) fluids prior to discharge. Studies have shown that pushing early fluid intake only promotes post-operative nausea and vomiting (PONV.) It is far better to wait until the patient feels thirsty, and this need not delay discharge home.

After major or unusually painful procedures anesthesiologists are increasingly being asked to prevent and treat the pain. Depending on the operation and your state of general health, we commonly can use indwelling epidural catheters, single-shots of micro-dose morphine into the spinal fluid, nerve blocks, intra-venous patient-controlled pumps, etc., to greatly reduce and in some cases completely eliminate post-operative pain.

Laboratory tests have proven over time to be unnecessary in many cases. We at OAG are working actively with our referring surgeons and hospital clinics to eliminate unnecessary testing while retaining those blood tests, x-rays, cardiograms, etc., that are still likely to help us avoid misadventures.

Occasionally a referring surgeon will encounter an unusual set of circumstances that warrant a visit with an anesthesiologist well ahead of the planned day of surgery to create a comprehensive plan for the ideal preparation for and performance of the anesthetic. These pre-op consultations are arranged within the group practicing at the site involved.