The traditional practice of Anesthesiology has expanded greatly and now includes caring for patients perioperatively. Our surgical colleagues have requested assistance in the management of some aspects of perioperative care. Thus, we have taken a broader view of the patient’s clinical experience and provided care in and out of the surgical room. The main difference between advanced perioperative anesthesia care and traditional anesthesia lies in the anesthesiologist knowing their patient preoperatively. Depending on the patient’s individual needs, their preoperative assessment includes performing a comprehensive review of their past medical history, assessing their current health status, and obtaining any additional testing required to keep the patient safe during anesthesia while maximizing organ function (kidney and liver) and controlling diabetes and brain perfusion. All of this can be done by an experienced anesthesiologist with an in-depth knowledge of Pharmacology, Internal medicine, and General medicine as well as various anesthetic procedures in order to create a safe intraoperative and postoperative environment for the patient. To do so, anesthesiologists usually take care of post-operative organ monitoring and manage the patient’s hemodynamic, analgesic, and general preparedness for rapid and optimal recovery. Traditionally, anesthesiologists would give their favorite combination of medications to put a patient to sleep, manage the blood pressure, and manage the depth of the anesthetic intraoperatively and post-operatively. Nowadays, anesthesiologists play a much more active role in the actual medical management of the patient; from the immediate preoperative period to the point where the patient may be discharged.

If the anesthetic is provided in a cookbook fashion, then there are many risks to anesthesia. But if you are in the hands of an experienced anesthesiologist your anesthetic will be altered to minimize all risks for your specific case and for your specific medical problems. Therefore, done appropriately an anesthetic can be very safe even for very severely ill patients.

Just as every patient has the right to choose their surgeon, they also have the right to choose their anesthesiologist. It is the anesthesiologist that keeps them safe and well during an operative procedure and it is the anesthesiologist who is the most effective physician to manage their pain postoperatively.

Yes, every patient has the right to choose their anesthetic. However, it ismy job to explain what options are available, to do a certain procedure, and to make clear to the patient which would be the best option for him. For example, if a certain procedure is amendable to a regional anesthetic that is almost always the best option. The reason is that this will allow the body to be operated on with zero acknowledgment of the operation itself. In other words, the body does not recognize the surgical trauma, because the nerves are blocked. So, there are no messages going to the central spinal cord and to the brain of surgical trauma- it's like tricking the body into thinking it's not being operated on, so this is always the best anesthetic. Now, in some people, we are not able to perform regional anesthesia, for example, if somebody is with very high anticoagulation because of the risk of bleeding in certain areas (like the central spinal cord) we would not be able to place an epidural. However, we can do peripheral blocks under anticoagulation depending on the surgical area. So again, it is the anesthesiologist’s job to recommend the best anesthetic to each patient.

In general, we allow our patients to take all of their medications before surgery except for anticoagulant medications- excluding aspirin. Aspirin is often allowed for most surgeries but the more advanced anticoagulants (like Warfarin, Plavix, Pradaxa) and many of the others usually are stopped for several days prior to your operation and that depends on the drug itself. Some drugs require one or two days, others require up to four or five days to be stopped prior to the operation. ​ In addition for diabetic patients, we usually want them to take half of their long-lasting insulin dose the night before surgery because the following morning they will not have a full breakfast and the morning of surgery again they take half of their long-lasting insulin and none of their regular insulin. The anesthesiologist from that point on will monitor their glucose and adjust it accordingly.

The American Society of Anesthesiologists has given the following recommendations: 6 hours for solid meals prior to surgery and 2 hours of clear liquids prior to surgery ​ So a patient can have a normal diet up until six hours preoperatively and clear liquids up two hours preoperatively.

If you are in the hands of an experienced anesthesiologist there are multiple mechanisms for us to recognize the depth of anesthesia that the patient currently has and that is something that is adjusted throughout the surgery. In other words, our monitors are enough to allow us to recognize when a patient is getting lighter in their anesthetic depth and we very easily can deepen their anesthetic at that point. We also can lighten an anesthetic when our monitors reveal that their depth is too much more than what the surgical procedure requires. Even with a regional anesthetic the IV sedation that we give, usually keeps a patient sleeping lightly so that they do not recognize what is happening during an operation.

Most people don't realize that if their pain is not managed during their surgery, there will be very deleterious effects in their postoperative state. First, their pain will be much more severe post operatively and their healing process will be slowed because of this stress that was created from the intra operative pain. So yes, your pain will be managed intra operatively! We have amazing medications intravenously to block pain signals to the spinal column and to the brain and we also have regional anesthesia which blocks any messages of surgical trauma or pain 100% from entering the central spinal cord or the brain. With these mechanisms we block intra operative pain, we try to make it zero, so that their postoperative recovery will benefit with minimal discomfort and with a rapid recovery.

There are many different ways to combat surgical pain even before it happens. We already discussed that this has to begin intra operatively before the surgical trauma happens. So we block pain before it happens, we keep it blocked during the entire surgical procedure and post operatively we have multiple mechanisms to control pain - depending on where the surgical sight is. Whether that is with regional blocks or with IV medications or with a combination of both.

In the past, we used to use large endotracheal tubes thinking that those were required to safely and quickly wean a patient from our ventilators intraoperatively. New data have shown that those tubes merely cause sore throats, hoarseness of the voice, and other difficulties which smaller and much softer endotracheal tubes these days do not cause. In addition, if a patient has a difficult airway and there are multiple attempts at intubation, then it is already foreseeable that they might end up with a sore throat postoperatively. To prevent this, we usually anesthetize before we attempt our procedures on the airway and if it continues to be difficult we wake the patient and do an awake fiberoptic intubation which is safe and which causes no damage to any of the tissue of the oral pharynx or the larynx. So the answer is, you may have some slight discomfort in your throat postoperatively but if done appropriately, this is a very rare occurrence.