Below is a list of some frequently asked questions, but please feel free to contact us if you need additional information. We are always pleased to assist you.
For your safety, it is very important that your stomach be empty before you have surgery and anesthesia. An empty stomach significantly decreases the chance of having aspiration, a rare but serious complication of both general and regional anesthesia with sedation. It occurs when stomach contents are regurgitated into the lungs, causing significant damage. You can protect yourself from aspiration by carefully following preoperative instructions regarding food and drink. In general, you will be instructed not to have anything to eat or drink after midnight the night before your surgery. You may be permitted to have some clear liquids (any liquid you can see through) up to 4 hours before surgery. You will be given specific instructions about eating and drinking by the nurse who contacts you the day before your surgery.
Given the thousands of medications on the market today, it is impossible to address each one individually. If you are scheduled to have a preoperative medical clearance, you should discuss this question with that physician. All patients scheduled for ambulatory surgery receive a phone call from an HSS nurse on the afternoon or evening before surgery. Medication questions should be discussed with that nurse. Finally, if your medication questions are not answered by the day of surgery, bring your medications with you. If you did not take one of your usual medications up until the time of your arrival at HSS, we may ask you to take one here, prior to your surgery.
Prior to the day of your surgery, if you have any questions or concerns related to your anesthesia, you are welcome to call us. An in-person preoperative consultation may be arranged if you wish. An anesthesiologist may be consulted by calling the Department of Anesthesiology at 212.774.2468. After office hours and on weekends or holidays, you can call Hospital for Special Surgery's page operator at 212.606.1188 and ask for the anesthesiologist on call, beeper #21530.
All patients meet their anesthesiologist on the day of their operation prior to the time of surgery.
If you have any questions about your operation, you should contact your surgeon.
Many people who come for surgery have allergies and it is extremely important that you inform your anesthesiologist of these. Your anesthesiologist (and the other doctors involved in your care) need to know not only what you might be allergic to, but also what type of reaction you had to that substance. Patients can be allergic to a variety of substances such as environmental particles, drugs (including anesthetics, antibiotics, pain medicines, etc.), latex, and foods or food components (eggs/milk, fruits, etc.). It is important to note all of these on your preoperative form and to inform your health care team. Almost everyone you meet at HSS from physician's assistants and nurses to your surgeons, anesthesiologists and internists will ask you about allergies. You will even be given a wristband that indicates what drugs or substances you are allergic to.
Since not all reactions to medicines or other substances are true allergic reactions, it is important to specify exactly what happened as a result of a previous exposure. If you do not know what the reaction was, it is ok, still include that substance as a possible cause of allergy.
Some people have allergies specifically to anesthetic agents. These can range from typical allergic reactions that cause skin rashes, hives, breathing problems and/or anaphylaxis to a very rare condition called malignant hyperthermia. It is especially important that your anesthesiologist know of any history of these types of reactions. Your anesthesiologist can find safe, alternative ways of giving you anesthesia without using those substances that have caused problems in the past. For your safety, your anesthesiologist may even recommend preoperative testing by an allergist to confirm true drug allergies.
If you do have an allergic reaction in the hospital, it can be treated. However, the safest way to avoid these types of problems is by avoiding exposure. This is why your reporting of previous allergic reactions is so important.
The anesthesiologists at HSS are very knowledgeable about the issues surrounding pain medications and surgery. In general, we are able to keep you safe and comfortable regardless of the medications you are taking for pain preoperatively. If you are taking large doses of pain medication before your surgery, if you have any implanted pain devices (a spinal cord stimulator or implanted opiate pump), or if you have reflex sympathetic dystrophy (RSD or CRPS) you should contact the Department of Musculoskeletal and Interventional Pain Management at (212) 606-1865 or the Department of Anesthesiology at (212) 774-2468 for a preoperative consultation with a chronic pain specialist here. This is very important, as it will allow us to develop a specialized care plan for your postoperative pain treatment. At HSS we have a dedicated Acute Pain Service to address pain issues postoperatively. Often, the Department of Musculoskeletal and Interventional Pain Management is consulted for management of your pain when you have been taking large doses of pain medications before your surgery.
In general, if you are taking pain medications preoperatively, you should continue your pain medications right up until the time of surgery.
Sleep apnea is a relatively common disorder seen in our patients undergoing surgery. Although many patients with sleep apnea are admitted with the diagnosis, some patients are only diagnosed in the operating room by the anesthesiologist from the pattern of their breathing.
If you know that you have sleep apnea, please alert your surgeon, anesthesiologist, and the hospital staff. Special home equipment for sleep apnea such as nasal CPAP should be brought to the hospital the day of surgery. As a precautionary measure, patients with sleep apnea are usually observed in the recovery room overnight to ensure that opiates (narcotics) or other pain killers prescribed to control pain after surgery do not interfere with respiration. The recovery room allows for constant monitoring of your breathing (which is not possible in a regular hospital room). If you have any further concerns regarding sleep apnea and anesthesia, please contact the Department of Anesthesiology at 212.774.2468.
The anesthesiologists at Hospital for Special Surgery play an important role in your upcoming surgery - administering anesthesia to ensure your comfort and enabling your surgeon to perform the procedure. Your surgeon may also consult our Acute Pain Service to treat your post-surgical pain.
Like charges from your surgeon, your anesthesiologist's fees are not included in your hospital bill. Many insurance plans cover our charges in full but some do not. While all of our physicians participate with Medicare and Medicaid, we may not participate with your specific insurance plan. To obtain information about your particular insurance plan, we recommend that you contact your insurer.
Regardless of your insurance coverage, you will receive a bill for anesthesia services. Our billing company (BSI - Billing Services Inc.) will also file this claim directly with your carrier. In many cases you may be required to intervene with your insurance company to ensure that they cover all the charges they should. BSI will assist you in this process. If you have an outstanding balance after your insurance payment you will be responsible for that amount. In the case of financial hardship or other extenuating circumstances, you must contact BSI to resolve the matter.
If you have further questions about our billing practices, please feel free to contact BSI toll-free at 888.877.3850.
An anesthesia bill is generated based on three factors: the complexity of the surgical procedure, the duration of the surgical procedure, and the medical complexity of the patient. These measures are reflected in what is called "relative value units". A unit is a 15-minute interval of time or relative value for complexity. The more complex the patient and procedure, or the longer the surgery, the more units are generated for a case. Once the units are generated, this number is multiplied by a conversion factor, which is a dollar value customary to the local area.
Patients may also be charged for other add-on procedures that are actually separate from the basic anesthesia. These procedures would include, but are not limited to the insertion of the arterial line, a swan-ganz catheter, or any other monitoring device that the anesthesiologist feels is necessary to ensure the safety of the patient intraoperatively. There is also a possibility that a surgeon would request that a separate nerve block be placed at the time of anesthesia so that the patient would have extra pain relief after surgery.
For further information on anesthesia charges, patients may call the Department's billing company:
Billing Services, Inc.
Anesthesia safety has dramatically improved over the last 50 years. The reasons for this improvement are numerous and are better understood by viewing anesthetic care in three stages:
You will be seen by your anesthesiologist before going to the operating room. This allows your anesthesiologist to better understand all the medical issues you may have which might have an effect on anesthesia. Any pre-existing medical conditions you may have are well evaluated and treated by your regular medical doctor, so that you are in the best possible medical condition for your surgery.
The intraoperative care provided by your anesthesiologist has greatly improved by advances in patient monitoring techniques. Your anesthesiologist continually monitors your breathing, cardiac function, oxygen levels, exhaled carbon dioxide, and blood pressure. Anesthetic drugs and techniques have also improved greatly, increasing safety and reducing side effects.
Finally, in the postoperative care unit (recovery room), you will continue to be monitored until the effects of anesthesia have diminished and you are able to either go home, or be moved to a regular hospital room.
Neuraxial blockade (i.e. "epidurals" and "spinals") with local anesthetic medicines can and do cause temporary interruption of muscle strength and sensation. These effects are expected and desired during surgery. The duration of these effects is determined by the amount and type of local anesthetic medicine given and these in turn are selected based on the requirements of the surgery and surgeon. These effects wears off over a period of minutes to hours in the recovery room (post anesthesia care unit/PACU).
Permanent or long lasting paralysis from epidurals or spinals (although possible) is exceedingly rare. Although difficult to precisely estimate, this risk lies somewhere between one in tens of thousands to one in hundreds of thousands of cases. This can be compared favorably to the risk of a fatal automobile accident in a single year (roughly one in four thousand). The causes of neuraxial anesthesia-related paralysis include direct nerve trauma, infection, and bleeding. In order to reduce the risk of paralysis (which is already very remote), special care is taken in the selection of the placement site for these anesthetics, the sterility of the procedure and avoidance of certain medicines and medical conditions that increase bleeding risk.
If you are concerned about this issue, please discuss it with your anesthesiologist before surgery. During general anesthesia, it is extremely rare to experience what is referred to as "recall". However, this is dependent on the anesthetic technique and the amount and type of drugs that are administered by your anesthesiologist. During regional anesthesia (i.e. spinal, epidural, or nerve block) you may choose to be anywhere from wide-awake to fully asleep. Many of the sedatives used have memory-blanking properties, and although you may be awake and conversant during the procedure you may have no recollection of these events later, (this is known as conscious sedation or "twilight sleep"). Your level of consciousness is very much under the control of your anesthesiologist. In many cases, your anesthetic can be "customized" to meet your expectations.
There are many safeguards on our national blood supply to ensure safe blood for patients. First, blood is donated by volunteer donors. Before giving blood, donors must answer questions about their health and risk factors for disease, and only a person with a clean bill of health can give blood. Blood from each accepted donor goes through extensive testing. In addition to tests for blood type, nine separate screening tests are run for evidence of infection with hepatitis, HIV, HTLV and syphilis. Finally, a carefully identified blood sample is tested against blood from the patient who will receive it, a process called crossmatch. Additional checks are then performed to compare the specific donor unit selected with the patient's blood.
If a blood transfusion is indicated during a surgical procedure or other medical treatment, the risks of NOT receiving blood far outweigh the risks of transfusion. Some patients may experience minor changes in the body's immune system after a transfusion, causing mild symptoms, such as fever, chills or hives, which typically require little or no treatment. A small number of patients may also react to donated blood by developing antibodies (immune reactions).
The transmission of disease and the destruction of red blood cells occur only very rarely, and seldom threaten life. The potential risk of contracting AIDS from a blood transfusion has received a great deal of attention. But it is important to know that all donated blood in the United States is tested for the AIDS virus, reducing the risk to a negligible level. When you consider the risks of transfusion, it may be helpful to know that many common activities carry far greater risks - for example, smoking cigarettes, driving a car or being pregnant.
You do have choices other than receiving blood from the community blood supply. Autologous blood transfusion refers to procedures in which you may serve as your own blood donor. In preoperative autologous donation, your blood may be collected and stored before a scheduled surgery if blood use may be required. In intraoperative and postoperative autologous transfusions, blood lost during surgery is saved and returned to the patient. Directed donations can also be arranged in some cases from a person (usually a friend or relative) whom you select.
The decision to have surgery is a difficult one. However, when parents have to make the decision for their children to have surgery is can be an emotional rollercoaster. In order to make this decision easier here at Hospital for Special Surgery we have Pediatric Anesthesiologists who specialize in all aspects of the care of children undergoing surgery. In fact, two of our anesthesiologists are dual-boarded in Pediatrics and in Anesthesiology. Parents can find comfort in knowing that their concerns are our concerns and we have developed a multidisciplinary approach for the care of their child that will ensure that every possible need will be addressed.
It is sometimes possible to watch surgery (on a video monitor) if it is arthroscopic surgery performed under a regional anesthetic. It is not possible to watch "open" procedures. During any regional anesthetic it may be necessary to also administer sedation or a general anesthetic, either to manage anxiety, to supplement the nerve block, or to stop patient movement during surgery. Patients undergoing arthroscopic surgery of the knee often find it informative and comfortable to watch. Arthroscopic surgery of the shoulder is a different matter. Unsedated patients are usually comfortable during the first few minutes of a shoulder arthroscopy, but commonly experience unpleasant referred sensations (pain) during the remainder of the surgery. Unsedated patients also often find it difficult to avoid moving during shoulder surgery. Elbow and hip arthroscopy may be performed in positions that make it impractical for the patient to watch the surgery.
The good news is that even if you have back pain you are generally an excellent candidate for spinal and epidural anesthesia. In fact, epidural steroid injections are often used in the treatment of back pain. Because epidural and spinal anesthesia offer significant benefits including decreased blood loss, improved surgical conditions, better post-operative pain control and decreased risk of potentially dangerous blood clots, pre-existing back pain should not be considered a contraindication for surgery.
You may experience back pain after spinal or epidural anesthesia, but this is not from aggravation of disc disease. One cause of post-operative back pain in ambulatory surgery is called TNS (transient neurologic symptoms). While the cause of TNS is not precisely clear, you may expect full resolution within a few days and excellent relief with anti-inflammatory drugs. Some people may experience short-term aggravation of back pain from preoperative discontinuation of non-steroidal anti-inflammatory drugs (NSAIDs, such as Celebrex, Mobic, Ibuprofen, Naproxen) prior to surgery, which improves when these medications are resumed after surgery. Lastly, careful positioning and padding during your surgery limits the risk of postoperative back pain.
Addiction or psychological dependence is extremely rare for people taking opiates for short-term pain control after an operation. The available data confirms the idea that fear of opiate addiction should not be a primary concern in treating postoperative pain. In fact, there is excellent evidence that good postoperative pain control is crucial to facilitate early mobility and a complete rehabilitative process. Tolerance (where the body becomes resistant to higher and higher doses of opiate medication) and physical dependence (where the body goes through a withdrawal syndrome after discontinuation of the medication) can develop with long-term use of opiates, but is exceedingly rare in the postoperative setting. Tolerance and physical dependence are often confused with but not the same as addiction or psychological dependence.
If you have a history of alcohol and substance abuse your surgical anesthetic and postoperative care can be designed to minimize the likelihood of problems. There are many things to consider in planning the type of anesthetic for any given surgery. To begin with, open and honest communication between yourself and your anesthesiologist beforehand will minimize any potential problems afterwards.
Substance abuse presents unique challenges to your anesthesiology team. Depending on the surgery, different forms of anesthesia may be employed. The simplest would be a pure local anesthetic technique. This can be done for minor surgical procedures such as carpal tunnel releases and removal of hardware. If the surgery involves an extremity or joint, a regional anesthetic technique can be employed. Examples include spinals for total hip and knee replacements, ACL repairs, and knee arthroscopies. Ankle blocks may be used for bunion and other foot surgeries, while brachial plexus blocks are used for hand, arm, and shoulder surgeries. In each case, minimal use of sedatives and opiates can be employed. The last option is general anesthesia, which is usually necessary for spinal surgery and more complex joint surgery.
The unique problem facing individuals with a history of addiction undergoing surgery is whether relapse can or will occur. Because most patients in the perioperative period will require painkillers or sedatives at some point during their hospitalization, this is a legitimate concern. Fortunately, for the vast majority of these patients, the use of these medications in this particular setting does not lead to reoccurrence of their addiction.
Some patients are concerned that the use of benzodiazepines (a class of drugs that include Versed, Valium and Ativan) will be problematic. These medications are often used preoperatively to alleviate anxiety about going into the operating room, and for sedation during the placement of local and regional anesthetic techniques. There are no studies to suggest that the use of these medications will cause patients with a history of alcohol dependency to relapse or develop a problem in the future with this class of medications.
For patients with a history of substance abuse, the opiates used to treat pain in the postoperative setting may also cause concern. For these patients, the judicious use of these medications, often in consultation with a chronic pain specialist, will reduce the likelihood of relapse while still adequately treating postoperative pain. In addition, careful observation after discharge with limited prescriptions for pain medications (i.e. a 1-2 week supply), along with a definitive follow up plan will also lessen the possibility for problems afterwards.
Nausea and /or vomiting are commonly associated with anesthesia and surgery. The reasons are complex, multi-factorial and relate to the type of anesthesia, the surgery itself, and the medications used to treat postoperative pain. You are at increased risk for postoperative nausea and vomiting if you are female and/or have past experience of postoperative nausea and vomiting or a history of motion sickness.
Fortunately, your anesthesiologist has a number of medications to treat this problem. These medications work best when they are given before the symptoms of nausea and vomiting arise. You should feel free to discuss your concerns about nausea and vomiting with your anesthesiologist in the holding area before surgery begins. This way, a plan to prevent or at least minimize this very unpleasant aspect of surgery and anesthesia can be formulated.
Postoperative pain control is an important focus for us at Hospital for Special Surgery. Your anesthesiologist plays an essential role in planning and maintaining your comfort during and after your surgery. Surgery in general and orthopedic surgery specifically results in postoperative pain. To eliminate pain totally after surgery would require complete anesthesia, and the resulting motor weakness and lack of tactile sensations would hinder the recovery and rehabilitation process. Furthermore, pain medications can have side effects such as sedation, nausea, vomiting, or disorientation. The goal of postoperative pain management, therefore, is to control the pain and reduce it to a level that does not distract you from your daily activity and enables you to function and participate with physical therapy. Initially after surgery, pain is managed by various modalities, including epidural infusions, local anesthetic infusions near peripheral nerves, or intravenous/patient controlled infusions of opiates (PCA). As pain gradually lessens in the days following surgery, you will be switched to oral medications. Usually, before going home your surgeon will write you a prescription for medication for pain control to be taken after you leave the hospital.
A blood clot will form within a blood vessel when there is damage to the blood vessel wall. This occurs when the rate of blood flow is diminished, or when these is an increased clotting tendency (hypercoagulability). The rate of blood clot formation varies greatly, depending on the type of surgery. Total hip and knee replacements have some of the highest rates of deep venous thrombosis of the leg, generally felt to be 30-50%. While most of these blood clots do not cause symptoms, about 1 in 100 patients having a joint replacement will have a clot break off and travel through the heart to the lungs (a pulmonary embolus) which can profoundly affect circulation and respiration. HSS is a nationally recognized leader in epidural anesthesia, which reduces the risk of these complications by 20-50%
Smoking, obesity, and estrogen all increase the risk of blood clot formation. You may want to discuss modifying these risk factors with your doctor prior to surgery. Be sure to tell your doctor if you've had a pervious blood clot.
Postoperatively, you can promote blood flow and reduce your risk of blood clots by doing exercises that will be prescribed, and walking with assistance as soon as possible. You may be given a medication to make the blood less coagulable and/or given a device that intermittently squeezes your calves or feet to promote blood flow.
HSS has been in the forefront of reducing the risk of blood clots after surgery. Research is ongoing and you may become aware of clinical studies designed to increase our knowledge and further reduce the risk of blood clots.
In general, if you have any questions about your operation, you should contact your surgeon.
If you have any questions or concerns related to your anesthesia, you are welcome to call us. An anesthesiologist may be consulted by calling the Department of Anesthesiology at 212.774.2468. After office hours and on weekends or holidays, you can call Hospital for Special Surgery's operator at 212.606.1188 and ask for the anesthesiologist on call, beeper #21530.
After your surgery is over, your anesthesiologist and your surgeon (or surgeon's assistant) will take you to the Post-Anesthesia Care Unit (PACU). If the operation is a simple one you may already be wide-awake, or if your surgery is more complex you could still be sleeping. In the PACU a nurse is assigned to your care and will continue to assess your well-being by checking vital signs such as blood pressure and heart rate, your level of wakefulness, and your pain control requirements.
During this period your family will be able to come and see you. For patients having surgery on the 4 th floor (check-in room 450W) families are asked to wait in the Family Atrium, which is on the same hospital floor (4th) as the operating rooms, and PACU. In the Atrium, volunteer staff are present who can find out for your family when your operation is finished. They will also be able to escort your family to the PACU to visit with you. Times for family visits start at twelve noon and are then repeated at three, six, and eight o'clock. The visiting time is for fifteen minutes and only one family member is allowed in at a time.
Once you have recovered from anesthesia and the medical staff has assessed that your condition is stable, you will be discharged from the PACU to your room. Here family members are welcome any time from twelve noon onward until eight o'clock at night.
If you are having ambulatory surgery, the check-in room (first floor, room 101) serves as the family waiting area. After surgery, ambulatory surgery patients are taken from the operating room to the Ambulatory Surgery PACU on the 1st floor, where they recover from their operation. Your family can visit as you recover. Visiting is at the discretion of the PACU nursing staff, and only one family member is allowed in at a time.