Expert: Dr Ian Jackson - please note UK based - 11/21/2008

Question
QUESTION: Hi Dr jackson; great website.  I'm scheduled to have hand surgery for trigger thumb, the ortho doc said that she would do the procedure with a Bier Block.  I'm requesting that this be done without sedation because I have had terrible experiences with it in the past (for some reason, I have a paradoxical to them, causing severe anxiety and panic, something that I found most unpleasant).  I had elbow and wrist surgery done at another hospital in the past with a Bier Block (left was fine without sedation, right was awful with propofol).  My problem is:  the anesthesia department seems to think that sedation is required for the Bier Block; my past experience says that it is certianly no.  My surgeon doesn't care and said that they could just give fentanyl for pain if needed without sedation; I asked anesthesia and they said that if I refused the sedation that i couldn't get fentanyl with the block.  Am I missing something here?  My doctor said that she thought that anxiety would not be an issue; the only anxiety that I have is from getting the sedation which makes me sick..even hen I got it, it certianly did not make the procedure any more comfortable, it actually made it much less comfortable.  The anesthesia rpoviders indicated that they would "do it their way" no matter what I had requested; my doc said to write "no sedation" on the consent.  Sorry for such a dumb question; I realize that most people find sedation desireable..I don't. Can you think of any reason that they would tell me "no painkiller unless I agree to sedation"?  Seems a little one-sided to me; i was polite when I made the request..I'm starting to think that they don't like me.  Thanks.

ANSWER: Hi Garry
Sedation is not required for thumb surgery. You have previous experience with Bier's Blocks and so you know what to expect. I can only imagine that the anaesthetists are classifying the fentanyl as a sedative - which it can be - and this is the reason they are making these stataments.
Rest assured you are not being unreasonable and you could state that you do not want to receive sedatives such as propofol and midazolam but would be happy to have fentanyl (which is mainly an analgesic but you realise may have a sedative action) during the procedure.
There is a slight issue that the anaesthetist may feel that he cannot care for you on the day but that would be an extreme standpoint! Hopefully that won't happen.
Hope this helps
Dr Ian Jackson



---------- FOLLOW-UP ----------

QUESTION: Thanks Dr Jackson-I met with the anesthesia provider this morning when I was at the hospital for preop blood workand to complete the surgical paperwork. They tried to tell me that "sedation is required if you get a narcotic", which I told them was wrong and they reluctantly told me that it really was not (without your information, I would have never got the truth)...my confidence in these people is a little low; although I believe that they were concerned about my comfort, just not honest..So now they will do the Bier Block without sedation and I told them to keep the fentanyl if it is an issue.  Then they asked me to sign a consent for general anesthesia "just in case" the block is ineffective.  Is this reasonable?  Maybe I'm a little distrustful of these people, or can I just tell them to abort the procedure rather than do general?  I asked my doc and she was very supportive and said that she could do my thumb with just local anesthesia and avoid the anesthesia part all together (although she said that it would not be comfortable).  Is it normal to erquest consent for general "just in case"?  Thanks again for all of your help.

Answer
You can sign the form for GA OK as you will be awake and they can't put you to sleep without asking if thats what you want. They will only ask this if you are in severe pain during the operation and iv fentanyl doesn't work to alleviate it.
I always mention this possibility to all my LA patients - doesn't mean I do it but once in a blue moon it is needed.
Glad you're getting sorted out.
Ian