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Importance of Anesthesia

Guest: Dr. Alex Cravanas, an anesthesiologist with University of Louisville Physicians.
Season 13 Episode 7 Length 28:34 Premiere: 10/22/17

Anesthesia: Blocking Pain for Better Outcomes

The use of pain management during surgical procedures dates back to the dawn of medical practice, and in the 19th century, several important breakthroughs were made by physicians who developed highly effective medications and treatments comprising the field of anesthesiology. Since then, more improvements have been made, giving the surgical team a wide variety of options to consider when assessing the perioperative (before, during, and after surgery) needs of the patient.

In this episode of Kentucky Health, Dr. Wayne Tuckson speaks with a University of Louisville anesthesiologist about the latest innovations in the field and about the best practices of applying anesthesia in order to ensure full surgical recovery.

Dr. Alex Cravanas, MD, is an assistant professor of anesthesiology at the University of Louisville. He has seen major advances in technology used in providing anesthesia as well as increased knowledge and expertise within the ranks of anesthesiologists as they gain a better understanding of how to alleviate pain.

General anesthesia, where the patient is made completely unconscious, is very safe, Cravanas says, and it is necessary for most major surgical procedures. “The goal of anesthesia is manifold,” he says. “What we’re trying to do is achieve safely the needs of the surgeon, in order to successfully complete the operation, and then also take into account any of the co-morbidities or ailments that the patient comes to surgery with, and craft the safest anesthetic plan that will achieve those goals.”

Administering Anesthesia Successfully
Using a series of slides, Cravanas lays out the modern operating room and describes the equipment used by an anesthesiologist during a typical surgery. The anesthesia machine contains monitors and also a ventilator, and it is the communications hub between the anesthesiologist and the rest of the surgical team. Using the machine, Cravanas says anesthesiologists are able to regulate “the patient’s body to behave in the way it would if the patient was awake and able to control their own functions.”

Anesthesiologists monitor heart rate, oxygen levels, blood pressure, body temperature, and a host of other vital signs. In order to transition a patient into unconsciousness, the anesthesiologist will use several drugs.

“The most common is nitrous oxide,” Cravanas says, “and we have volatile anesthetic agents, those would be anesthetic gases that are actually controlled through our anesthesia machine, that we can titrate and monitor the amount that’s on board, to allow us to maintain a reasonable amount of anesthetic that gives us some assurance that the patient is comfortable and asleep.” IV anesthetics such as Propofol are also available. To keep patients from moving involuntarily while asleep, muscle relaxants are administered.

Cravanas says the phenomenon known as wakefulness, where a patient under general anesthesia recalls feeling, hearing, or seeing the surgery being performed, is exceedingly rare. It is slightly more common in emergency room surgery and with pregnant or obstetric patients, but overall, the tools an anesthesiologist has at his or her disposal – being able to monitor brain wave activity, for example – gives them the ability to precisely “assess anesthetic depth” and make certain the patient is fully unconscious.

Most people view anesthesia through the prism of an actual surgical operation, but Cravanas says that a lot of the anesthesiologist’s most important work is done beforehand as they consult with the patient about health history and specific needs. This preoperative consultation “allows us to get a more global assessment of the patient’s co-morbidities and any other problems that they may have,” he says.

The checklist includes neurological status, acute injuries, heart health, lung health, kidney function, liver function, and so on. All physiological functions must be assessed, Cravanas notes, because any one of them may impair the administration of anesthesia. As an example, he explains how a patient on dialysis or with other significant liver issues may not be able to metabolize and excrete certain anesthetic drugs, and that will require adjusting the overall game plan.

Cravanas says that today, the two most significant challenges to providing anesthesia that he encounters are rising obesity in the U.S. and the opioid drug epidemic. Obese patients pose a challenge for the anesthesiologist in maintaining an open and clear airway for breathing, he says, and also in finding veins to use for an IV or a nerve block.

As for the opioid crisis, he says that “patients are coming to surgery not necessarily being what we term ‘opioid-naïve,’ which is what we would traditionally deal with,” but instead already tolerant of opioid pain medication due to their addiction. Such patients may require anesthesiologists to use a different pain management approach.

Other Options: Regional and Neuraxial Anesthesia
For many operations, especially those involving the extremities, general anesthesia is no longer required, Cravanas says. Regional anesthesia, where specific nerves are targeted in order to block the sensation of pain, is commonly used for operations in the leg or arm. Cravanas explains the process using a knee replacement as an example.

“For a knee replacement, we could do a femoral nerve block, which will basically cover the anterior portion of the knee,” he says, “and then we could do either a sciatic nerve block or, a little lower in the thigh, we could block the same nerve but we call it the popliteal nerve at that point, and both of those would provide complete coverage to the posterior knee, basically giving us complete anesthesia for the knee surgery.”

Neuraxial anesthesia injects pain-blocking medicine either the nerve roots in the spine, called an epidural, or into the spinal fluid around the spinal cord, called a spinal. They can be used in conjunction with nerve blocking in the lower extremities during regional anesthesia to provide excellent pain relief, Cravanas says. He also notes that while most major abdominal surgeries still require general anesthesia, an epidural can still be applied to help manage post-operative pain.

Overall, nerve blocks are generally just as safe as general anesthesia, Cravanas says, but the best procedure for each individual patient is something that will be determined during the pre-operative consultation.

“One of the things improved the safety and efficacy of nerve blocks is ultrasound use and being able to put the medicine exactly where we want it to go, without it being somewhere where we don’t want it to go,” he says.

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Season 13 Episodes

Public Health in Kentucky

S13 E25 Length 29:24 Premiere Date 04/15/18

Pain Treatment in the Age of Opioid Addiction

S13 E24 Length 28:57 Premiere Date 04/08/18

The Louisville Health Equity Report

S13 E23 Length 28:09 Premiere Date 04/01/18

Smoking in Kentucky: Hidden Cost Obvious Impact

S13 E22 Length 28:54 Premiere Date 03/25/18

Kidney Function and Renal Disease

S13 E21 Length 28:32 Premiere Date 02/25/18

Brain Tumors

S13 E20 Length 28:44 Premiere Date 02/18/18

Gastroenterology and Motility

S13 E19 Length 27:37 Premiere Date 02/11/18

Many Years, Many Medicines, Many Problems

S13 E18 Length 28:38 Premiere Date 02/04/18

A Day in the Life of an Ophthalmologist

S13 E17 Length 27:32 Premiere Date 01/28/18

A Day in the Life of a Thoracic Surgeon

S13 E16 Length 27:27 Premiere Date 01/21/18

Incontinence and Female Sexual Dysfunction

S13 E15 Length 27:51 Premiere Date 01/14/18

Building Healthy Communities

S13 E14 Length 28:44 Premiere Date 01/07/18

Music and Medicine

S13 E13 Length 28:34 Premiere Date 12/17/17

Health Ministries

S13 E12 Length 28:29 Premiere Date 12/10/17

Preventing Heart Disease

S13 E11 Length 28:40 Premiere Date 11/19/17

Prostate Cancer

S13 E10 Length 28:42 Premiere Date 11/12/17

Skin Diseases and Conditions

S13 E9 Length 26:22 Premiere Date 11/05/17

Treating Drug Addiction

S13 E8 Length 28:12 Premiere Date 10/29/17

Importance of Anesthesia

S13 E7 Length 28:34 Premiere Date 10/22/17

Public Sanitation Infrastructure

S13 E6 Length 26:39 Premiere Date 10/15/17

Health and the Outdoors

S13 E5 Length 28:47 Premiere Date 10/08/17

Universal Health Insurance

S13 E4 Length 28:43 Premiere Date 10/01/17

Strategies for Quitting Tobacco

S13 E3 Length 26:38 Premiere Date 09/25/17

Rural Physicians' Perspectives

S13 E2 Length 26:53 Premiere Date 09/17/17

Health Care in Rural Kentucky

S13 E1 Length 27:38 Premiere Date 09/12/17

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