“Do I need to be knocked out for this procedure?” And other questions about anesthesia overuse

Anesthesia, controlled temporary loss of sensation or awareness, is a necessary part of some medical procedures. But there are multiple different types of anesthesia, each with different levels of risk, and not all procedures require the same type of anesthesia. 

General, regional, local

Local anesthesia is common for small procedures that just require numbing of the area. Regional and general anesthesia are much more complex. For regional anesthesia, the anesthesiologist injects medication into a cluster of nerves to numb the extremity or area that requires surgery. General anesthesia is the most invasive option and also has the most acute associated risks: the patient is given a combination of medications that put them in a sleep-like state. The short term risks of general anesthesia are well-known, but we less commonly talk about any long-term risks. 

Depending on the surgery, there may be more than one viable option. Doctors are supposed to discuss the risks of general anesthesia and alternatives if available, as part of the informed consent process. However, this shared decision making conversation does not always happen, which can lead to overuse of general anesthesia. While rare, general anesthesia can cause serious adverse effects and even lead to death. In one extreme example, a young boy died from anesthetic after a visit to the dentist’s office for a tooth extraction. Stories like this make it necessary for clinicians to think critically about how and when we use anesthesia.

Potential for anesthesia overuse

The topic of anesthesia overuse came up during a recent conversation with a friend in her second year of medical school at the University of Vermont. I asked her some questions about how this topic is being explored in the medical school learning environment. 

In what scenarios could general anesthesia be particularly risky? 

“The two situations we have discussed at length for long-term risks are with children and older adults. In older adults we are worried about cognitive changes from surgery and delirium following surgery. In the US, approximately 30% of surgeries are performed on adults over 70. These patients are at higher risk for post-anesthesia delirium — basically an intermittent state of confusion, inability to sleep, and decreased attention that is not due to underlying disease. It is often caused by drug toxicity, infection, seizures, and hospitalization of any sort already places older adults at risk.

“When we do the math, this adds up to a lot of patients at risk for delirium each year. “

When we do the math, this adds up to a lot of patients at risk for delirium each year. If we could reduce this number, there is the potential to reduce length of hospital stays and harm caused by delirium.

In kids, we are worried about decreased school performance following general anesthesia in infancy. There have been studies conducted that suggest decreased school performance when kids have a history of general anesthesia.”

How do we make sure that patients are receiving the most appropriate type of anesthesia for their procedure?

“The decision about which type of anesthesia to use is often a shared decision or discussion between the surgeon and anesthesiologist. Many surgeons have strong preferences for which type of anesthesia they want patients to have for particular procedures. From their perspective, it might often be simpler if the patient is under general anesthesia because they will not be able to move. However, from an anesthesia perspective, general anesthesia is riskier. We have some data on the long term impacts of general anesthesia, but this discussion is just beginning to take place on a larger scale. 

Strong clinical guidelines that are enforced and reviewed (and improved) periodically may help improve patient outcomes. The procedures that we know are well-suited to regional anesthesia with light sedation should always use this option. Strong guidelines can help take some of the guesswork out of the decision making process.

“Instead of assuming general is appropriate until we find a reason not to use it, what if we came at it the other way?”

The medical community needs to reframe how we think about using anesthesia. Instead of assuming general is appropriate until we find a reason not to use it, what if we came at it the other way? So, for a lot of procedures maybe we could assume regional anesthesia is the right option unless we find a compelling reason that general is better suited for a particular patient’s needs. Of course there is never going to be a time when we are going to do open heart surgery without general anesthesia. General anesthesia definitely has a place in medicine, but I think we can think more critically about when and where that is – because it is an important tool that we have.”