It’s better to burn out than it is to rust.
Neil Young from the song “Hey hey, My my”
One of the great aspects of being a hand surgeon is the fact that almost all the surgeries that I do can be done as an outpatient. In fact I’m finding that I can safely do more procedures in the office as well. One of the main factors that determines where a surgery can be done is the anesthesia that is required. Patients have a healthy fear of being “put to sleep” and we have found that a great number hand surgeries can be done with local anesthesia. What I would like to talk about in this post is the different types of anesthesia that hand surgeons use and the various types of operations that can be done under the different types of anesthesia. I’ll start with the most complicated and move to the simpler methods of anesthesia.
General anesthesia, or being “put to sleep” is commonly used for longer and more involved surgeries. There has been a number of great improvements in the types of medications used for general anesthesia so that patients seem to have fewer problems from general anesthesia. Two of the most common side effects of general anesthesia are drowsiness and nausea and the newer medications have decreased the incidence of these complications. In addition many general anesthesia cases can be done with a device called an LMA (laryngeal mask airway) which avoids placing an breathing tube (endotracheal tube) into the trachea. This can avoid problems with throat irritation after general anesthesia. In my practice I do most major elbow surgeries under general anesthesia, and major surgeries around the hand and wrist that I expect will take longer than an hour or so I will do under general anesthesia as well.
Sometimes patients choose to have their entire arm “numbed up”. These are called “blocks” and the goal is to numb all the nerves to the arm and hand. The nerves can be blocked in the armpit or above the collar bone. This type of anesthesia is commonly done for shoulder surgery, but I don’t use it too often in the hand and wrist areas. The blocks probably work only about 75% of the time, and most people who need this level of anesthesia choose to go ahead and have general anesthesia.
Many of the surgeries I do are done with local anesthesia. Some patients choose to be sedated, and the medical term for the sedation is MAC, or monitored anesthesia care. In many cases some of the same medicines that are used for general anesthesia are used in the MAC but in lower doses than are used for general anesthesia. Most patients have the sensation that they are completely “out”. The purpose of the anesthesia is to avoid the pain of the injection of the local anesthetic and also to help control pain that can arise from the use of a tourniquet during hand surgery.
I have an increasing number of patients who choose to have their surgery done with local anesthesia only. If the surgery is being done on a finger then it is relatively easy to numb the entire finger and use a small finger tourniquet to do a number of different types of surgeries. I do a number of surgeries in my office using this technique, the most common one is to remove small cysts from fingers. Also there has been a recent upswing in the number of patients using local anesthesia for surgeries such as carpal tunnel releases or a procedure called a trigger finger release. Studies have shown that it is safe to use local anesthesia in the hand that has epinephrine in it. Epinephrine can greatly decrease bleeding and allow some surgeries to be done without a tourniquet. There’s some discomfort when the shot goes in, but once the incision is numb then the patient doesn’t feel any pain or discomfort during the procedure. This is a great way to go if you want to avoid any chance of having problems with nausea or sedation.
If you’re planning on having hand surgery certainly ask about the anesthesia options available. Every surgeon has different ideas but most surgeons should be open to using a number of different types of anesthesia to suit your needs.