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Is general anesthetic before surgery always the best option?

The Patient Navigator is a column that answers reader questions on how to navigate our health-care system. Send your questions to

The question

I have to undergo surgery. Is a general anesthetic warranted or can I opt for a local anesthetic?

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The answer

This particular reader was slated to undergo wrist surgery and didn't want a general anesthetic as she thought "going to sleep" was extreme for the removal of ganglion cysts, a knobby mass under the skin.

For that operation and many others, a general anesthetic is not required, says Brian Kavanagh, chair of the anesthesia department of the University of Toronto.

"There is a trend to doing more surgery awake or lightly sedated," he said, adding that many hip and knee replacements performed in Canadian hospitals are done under a regional anesthetic.

In addition, patients who undergo shoulder, arm or plastic surgery can often do well with a regional anesthetic, said Dr. Kavanagh, who works as a staff physician in the Hospital for Sick Children's pediatric intensive care unit.

Anesthesia tends to get little attention from patients, who are mostly focused on pending surgery. And yet, it is extraordinarily common with more than 1.3 million acute care patients receiving some form of it in this country's hospitals each year, according to data provided by the Canadian Institute for Health Information.

Anesthesia falls into two main categories: regional, in which part of the body is frozen with a numbing agent; and general, in which the patient is deeply unconscious and a breathing tube is often inserted down the windpipe.

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If you are scheduled to undergo surgery, you can discuss options during the first consultation with the anesthesiologist, which typically takes place days or a couple of weeks before an operation. That physician specialist is responsible for sedating, administering pain killers and observing vital signs during surgery.

Some examples of regional anesthetic include a peripheral nerve block, where a local is injected near a group of nerves or a particular nerve. It's mostly used in operations on the hands, arms, shoulders, hips and knees. With an epidural and spinal, a local anesthetic is injected near the spinal cord and nerves that connect to it, in an effort to suppress pain in a region of the body, such as hips, legs or belly. In those cases, patients can receive medicine to help them sleep or relax.

For some operations - such as coronary artery bypass graft surgery - patients have little choice as they must have a general anesthetic to be placed on a heart-lung bypass machine.

While most patients may question their anesthesia, there is one adverse event they worry about universally: being awake and in agony while the operation is taking place.

"That kind of nightmare scenario where you are aware and in pain is exceptionally rare, thank goodness," Dr. Kavanagh said.One significant issue is contentious in the medical community: the negative after-effect of general anesthetic on the brain. Some say general anesthesia can cause postoperative cognitive dysfunction, particularly in seniors whose memory is already compromised.

The bottom line

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During consultation with the anesthesiologist, discuss options and find the most suitable anesthetic for the procedure.

Elderly patients in particular should determine whether a general anesthetic could potentially worsen their cognitive function. If that's the case, they should vigorously explore whether another form of anesthetic is possible.

The Patient Navigator is a column that answers reader questions on how to navigate our health-care system. Send your questions to

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