National Hospital for Neurology and Neurosurgery General Anaesthesia for Neurosurgery Department of Anaesthesia

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If you would like this document in another language or format, or require the services of an interpreter, contact the Pre-operative Assessment Centre. We will do our best to meet your needs.

Contents

1 Introduction

2 What is a general anaesthetic?

3 Who gives a general anaesthetic?

4 What does your anaesthetist need to know?

5 What are the benefits, risks and side effects of general anaesthesia?

6 What if I choose not to have a general anaesthetic?

7 Preparing your body for a general anaesthetic

8 What happens during a general anaesthetic?

9 What should I expect after a general anaesthetic?

10 References

11 Where can I get more information?

12 How to contact us

13 Where to find us

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1 Introduction

This booklet has been written by the Department of Neuroanaesthesia at the

National Hospital for Neurology and Neurosurgery (NHNN). The aim of the booklet

is to provide you with some information about general anaesthesia for

neurosurgery.

It is intended for use by patients, their family or carers; it is not intended to replace a

discussion with your anaesthetist. Please do not hesitate to speak to a member of

staff, they will be happy to answer any questions you have.

2 Who gives a general anaesthetic?

A general anaesthetic is given by an anaesthetist, a doctor specifically trained in

anaesthesia, the treatment of pain, intensive care of very ill patients and emergency

care. At NHNN, anaesthetists are also trained in anaesthesia for neurosurgery

(neuroanaesthesia). Most people who come to NHNN for their surgery or

intervention will visit the Preassessment Clinic a few weeks before admission. You

will see a specially trained nurse or in some cases an anaesthetist. The purpose of

this visit is to gather information from you so that your anaesthetist has all tests and

results available on the day of your surgery.

3 Your anaesthetist will:

assess your health and discuss with you which type of anaesthetics are suitable for your surgery.

give you the anaesthetic and keep you safe during surgery. Your anaesthetist stays with you all the way through your operation. They will use modern monitoring equipment to assess your condition all the time during your operation. They will give you the drugs and fluids you need to keep you safe and well.

plan your pain relief to make you as comfortable and nausea free as possible in the recovery room after your surgery.

if you have had a long and complex operation, or are unwell, may take you to the intensive or high dependency care unit after your operation.

You may be seen and cared for by an anaesthetist training in neuroanaesthesia; however a consultant anaesthetist will always be responsible for your care. No one will care for you unless they are adequately trained to do so.

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4 What does your anaesthetist need to know?

Your general health and fitness

Any serious illnesses you have had

Any problems you may have had with previous anaesthetics (or if any family

members have had problems with anaesthetics), any pains in your chest,

shortness of breath or heartburn

All medicines you take, especially anticoagulantion or ‘blood thinning drugs’

such as warfarin, dipyramidole, clopidogrel, rivaroxaban, apixaban or

dabigatran and non steroidal anti inflammatory drugs such as aspirin,

ibruprofen (Brufen, Neurofen), naproxen and diclofenac (Voltarol) as they

affect the ability of the blood to form a clot. You may be asked to stop taking

these medicines a few days before you come into hospital.

Any allergies

If you have any loose teeth or any caps, crowns or bridges

Whether you smoke, drink alcohol or use recreational drugs

Whether you take herbal medication, as some can affect the way the blood

clots

Most people come into hospital on the same day of their operation, some will

come in the night before depending on the procedure

An anaesthetist will always see you before the operation and you will have the

chance to talk to your anaesthetist before surgery.

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5 What are the benefits, risks and side effects of general anaesthesia?

General anaesthesia has made much of today’s neurosurgery possible by removing pain, sensation and awareness. These benefits are weighed against the risks of the anaesthetic procedure and the drugs used. Risks vary from person to person and the risk to you as an individual will depend on:

whether you have any other illness

factors such as smoking, drinking excessively or being overweight

surgery which is complicated, long or done in an emergency

In modern anaesthesia serious problems are uncommon. Risks of general anaesthesia are thought of as side effects and complications. Side effects and complications The following index lists possible side effects and complications according to how likely they are to happen. As an example, if something is ‘very common’ it means that about 1 in 10 people will experience it. It also means it will not happen to about 9 out of 10 people. Very common - 1 in 10: Someone in your family Common - 1 in 100: Someone in a street Uncommon - 1 in 1,000: Someone in a village Rare - 1 in 10,000: Someone in a small town Very rare - 1 in 100,000: Someone in a large town Very common / common

Feeling sick and vomiting after surgery

Sore throat from the breathing tube

Dizziness or blurred vision

Itching

Pain during injection of drugs

Bruising and soreness

Confusion or memory loss

Shivering

Chest infection

Bladder problems

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Uncommon

Chest infection

Damage to teeth, lips, tongue or skin of face

An existing medical condition becoming worse

Nerve damage to peripheral nerves

Awareness (becoming conscious during your operation) Rare or very rare

Heart attack or stroke. The risk of this will depend on your pre-existing conditions.

Damage to the eyes including loss of vision. Very rarely patients can go blind after surgery in the prone position; this is when you are lying on your front during the operation. Risk factors include long operations and significant loss of blood. Lesser risk factors may include obesity, diabetes, high blood pressure and glaucoma.

Serious allergy to drugs

Nerve damage to nerves in the spine. Your surgeon may require you to lie in an unusual position, for an extended period of time, for the duration of your operation. Temporary or permanent nerve damage can be the result

Equipment failure

Death People who are very ill and have certain medical problems have a higher risk of death than those who are fit and well. Death caused by anaesthesia is very rare. There are probably about five deaths for every million anaesthetics given in the UK.

6 What if I choose not to have a general anaesthetic?

If you choose not to have a general anaesthetic your surgery may not be possible, but this can be discussed with your surgeon and anaesthetist.

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7 Preparing your body for a general anaesthetic

Lifestyle changes There are many changes you can make to reduce the risks of surgery. Even small changes can make a big difference. Exercise Your heart and lungs have to work harder after an operation to help the body to heal. If you are already active, they will be used to this. While you are waiting for your operation, try and increase your activity levels. Try to do any activity which makes you feel out of breath at least three times per week, first check with your doctor what type of exercise is most appropriate for you. Improving your strength and balance through activity will also be useful for your recovery. Who can help me? Your GP can refer you to an exercise scheme at your local gym. Depending on where you live you may have access to NHS ‘healthtrainers’ who can help motivate you and offer advice. Try joining a free council or community walking group or environmental volunteering scheme in your local area such as ‘Walks on Prescription’. Diet Eating a healthy diet before and after your surgery can really help to repair itself after surgery. Who can help me? Your GP surgery should be able to give you some advice and information on healthy eating. Weight If you are overweight, losing weight can help reduce the stress on your heart and lungs and help to:

lower your blood pressure

improve your blood sugar level

reduce pain in your joints

reduce your risk of blood clots after surgery

reduce your risk of wound infections after surgery

allow you to exercise more easily

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Who can help me? Your GP surgery can weigh you and advise on healthy eating and exercise opportunities in your community. People who are able to improve their lifestyle before surgery are much more likely to keep up the changes after surgery. This can have a positive health impact in the long term. Alcohol Drinking within recommended limits can improve your body’s ability to heal after surgery. Even small changes can make a big difference. Who can help me? You can find useful information on how to reduce alcohol and the benefits to you on NHS Choices. Also see the drinkaware website: www.drinkaware.co.uk Smoking Quitting or cutting down shortly before surgery can reduce length of stay in hospital, improve wound healing and lung function. Who can help me? Your GP practice will be able to offer help in reducing or stopping smoking, so ask them about the best options for you. Preparing your body for a general anaesthetic Medical conditions Many medical conditions can affect recovery from surgery. It is important to make sure any known conditions are controlled as well as possible ahead of your surgery. You can also book in for a general health check at your GP surgery if you are over 40 years old. Diabetes Good control of your blood sugar is really important to reduce your risk of infections after surgery. Contact your diabetes team to ensure you are on your best treatment. Blood pressure Blood pressure should be controlled to safe levels to reduce your risk of stroke. Have your blood pressure checked at your surgery well ahead of your surgery. If it is high, your GP can check your medications and make any changes needed ahead of the operation.

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Anaemia If you have been bleeding or have a chronic medical condition, a blood test can check whether you are anaemic. If you are, you should talk to your GP about treatment to improve your blood count before surgery. Treating your anaemia before surgery reduces the chance of you needing a blood transfusion. It can help recovery and make you feel more energised after your surgery. Heart, lung and other medical problems If you have any medical problems, consider asking your GP or nurse for a review of your medications, especially if you think your health is not as good as it could be. Anxiety and mental health Many people can feel anxious about having surgery. If this is the case for you, it may be helpful to talk about your concerns with your GP. GPs can refer you for specific support. Many techniques including mindfulness, relaxation and breathing exercises or yoga could help you relax before and after your surgery. If you are taking medication for mental health problems it is important to let the team looking after you know about your medication. They will usually not want you to stop your medication and can help organise any particular support you need. Dental health If you have loose teeth or crowns, a visit to the dentist may reduce the risk of damage to your teeth during an operation. How should I prepare for general anaesthetic? Before your anaesthetic you may be required to do all or some of the following to ensure that you are safely prepared. Getting ready for the operation

You will be asked to change into a theatre gown, and may be measured for compression stockings. These help prevent blood clots forming in your legs.

A member of staff will complete a checklist and escort you to theatre. You will either walk to theatre or use a wheelchair or trolley.

If you have glasses, hearing aids or dentures, you can wear them to go to the operating theatre. You will need to remove them before the anaesthetic begins so that they are not damaged or dislodged.

Your identifying details will be checked at different points along the way.

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8 What happens during a general anaesthetic?

In most cases a general anaesthetic is started in an anaesthetic room which is next to the operating theatre, or sometimes in the operating theatre itself. Your anaesthetist will stay with you throughout your anaesthetic and will be working with a trained assistant. Before you are given any anaesthetic drugs you will be connected to monitoring including:

a heart monitor on your chest

a blood pressure cuff will be put on your arm

an oxygen level monitor will be placed on your finger

Throughout the anaesthetic you will be monitored closely so any changes can be detected immediately and treated, if required.

A thin plastic tube is placed via a needle, into a vein in the back of your hand or arm and used to give drugs and fluids. Depending on the type of surgery, and on your general health, the anaesthetist may insert another cannula into an artery at the wrist. This cannula is called an arterial line. It allows your blood pressure to be measured continuously, and it is also used for further blood tests during the operation. When all of the preparations have been completed, you will be given oxygen to breathe through a mask. The anaesthetic is started by injecting anaesthetic drugs into a vein or in some cases by breathing a mixture of anaesthetic gases and oxygen through a mask. You will become unconscious within a minute or so. During the operation drugs and anaesthetic agents are continuously to keep you pain free and unaware. You will receive fluids as well as anti-nausea drugs. While you are anaesthetised, you may also have:

a breathing tube placed into the trachea (windpipe) through your mouth

a tube passed through the nose into your stomach which keeps your stomach empty

depending on your operation you may have a urinary catheter temporarily to drain your bladder

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Blood transfusion Blood transfusion is a possibility during all major surgery. Blood is only given if absolutely necessary. You can find out more about blood transfusion and any alternatives there may be by asking your anaesthetist beforehand.

9 What should I expect after a general anaesthetic?

In the immediate period after your operation you will continue to be closely monitored either in the recovery room, high dependency or intensive care unit if you require a longer period of monitoring. Your anaesthetist will tell you where you can expect to be after your operation. Ward patients Most people will wake up in the recovery area after surgery. A recovery nurse will be with you at all times. Here they will:

monitor your blood pressure, oxygen levels and pulse rate

give you oxygen through a mask

assess and treat your pain if required

give anti-nausea drugs if required

cover you with a warming blanket if you are cold

return your dentures, hearing aids and glasses You will be seen by your anaesthetist after your surgery and when you are well enough you will be taken back to the ward. It is important that any pain is well controlled to help you recover more quickly. Good pain relief assists mobilisation and helps prevent complications such as chest infections and blood clots. Your prescribed pain relieving medicines will be given to you regularly and also some additional ones. If these are not controlling your pain, you should inform a member of staff in order that your pain management plan is reviewed. Occasionally pain is a warning sign that all is not well so the nursing staff should be told about it.

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High dependency and intensive care patients You may need to go to intensive care or high dependency care (ICU or HDU) depending on your health or operation. If required you will be moved from the theatre to the Intensive Care Unit (ICU) or High Dependency Unit (HDU) where you will receive additional close monitoring and specialist treatment. Sometimes the anaesthetic needs to be continued after the operation has finished until your condition is stable. Your anaesthetist will take you to the ICU. The anaesthetic will continue and a breathing machine will control your breathing. When your condition allows, the ICU team will allow you to breathe for yourself and you will gradually wake up. On the HDU or ICU, you will be looked after by a team of doctors, nurses, physiotherapists, speech therapists and dieticians who specialise in high dependency and intensive care. They work closely with your surgical team to ensure that your recovery is proceeding well.

10 References

This booklet has been developed using information from the publications below: You and your anaesthetic. 4th Edition. The Royal College of Anaesthetists. www.rcoa.ac.uk/patientinfo Preparing for surgery. Fitter Better Sooner. The Royal College of Anaesthetists. www.rcoa.ac.uk/fitterbettersooner Your anaesthetic for major surgery. First addition 2014. The Royal College of Anaesthetists. https://www.rcoa.ac.uk/system/files/08-MajorSurgeryweb.pdf

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11 Where can I get more information?

Royal College of Anaesthetists Churchill House. Red Lion Square London WC1R 4SG Telephone: 020 7092 1500 25 Fax: 020 7092 1730 Website: www.rcoa.ac.uk Association of Anaesthetists of Great Britain and Ireland 21 Portland Place London WC1B 1PY Telephone: 020 7631 1650 Fax: 020 7631 4352 Website: www.aagbi.org Email: info@aagbi.org.

UCL Hospitals cannot accept responsibility for information provided by other

organisations.

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12 How to contact us

Pre-operative Assessment Centre National Hospital for Neurology and

Neurosurgery.Queen Square

London

WC1N 3BG

Switchboard: 020 3456 7890

Direct line: 020 3448 3348

Fax: 020 3448 8937

Website: http://www.uclh.nhs.uk/OurServices/ServiceAZ/Neuro/QSPAC/Pages/Home.aspx

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13 How to find

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First published: November 2015 Date last reviewed: January 2020

Date next review due: January 2022

Leaflet code: UCLH/NHNN/NGA/3

© University College London Hospitals NHS Foundation Trust