Expert: Ronald Levy, M.D. - 7/27/2010

Question
I'm a 35 year old woman, healthy. I'm having an ortho procedure on my thumb (a variation on a trigger thumb release) and the surgeon says that it can be done with local or soem procedure where they  inject novacaine and use a blood-pressure cuff to keep the novacaine in place. I told him that I didn't want to do the procedure with general anesthesia or any sedation (I had a terrifying experience with MAC) and he said that this would be no problem and he would prefer to have his own procedure done that way; it may hurt a little but that's o.k. On the day of surgery I cross out the part of the consent regarding general and or sedation and the CRNA tells me that I have no choice about what type of anesthesia that I get. I asked her to speak with the surgeon and when she returned she told me that it wasn't really his decision and that the anesthesia was her area.  I realize that they usually want to have flexibility in case the novacaine doesn't work, but in my case I will politely decline this because of past experience. I know that this is unusual, but I don't think that my request is unreasonable.  I understand that the CRNA (no anesthesiologists available at this facility) can refuse to do the case if they think that the request is unreasonable, but she didn't refuse, she just kept telling me that I was making a mistake etc.   Is there any problem with limiting my consent?  Also, the CRNA was asking me a lot of health questions (no problem), but one threw me and it's embarassing, she asked if I was constipated and I replied honestly that I was a litle but it's not a problem.  She told me that I shouldn't come for surgery constipated (yeah,I made a decision to do that) and that it could be a problem when receiving anesthesia.  I asked why and all she would say was that she had to take care of me and wouldn't explain.  The surgeon was delayed with the previous case and my surgery postponed, but I'll probably have the same nurse doing the anesthesia.  Why in the world would constipation be an issue, or is she just pulling my chain?  Thanks

Answer
First of all, I have never heard of any anesthesiologist asking about constipation and it has no bearing on your anesthetic. As for the anesthesia for the surgery, the two options you were given were either a local anesthetic or a Bier block (novocaine with the BP cuff). The problem with these is slightly different. With the Bier block, your hand will be numb but the blood pressure cuff will remain inflated for the duration of the surgery (at least 30 minutes) which could get VERY uncomfortable for you. The problem here is not only the pain but if it is too uncomfortable, they can't deflated the cuff because the Novocaine in the hand would then go to the heart and it potentially could be toxic (after 30 minutes, the effect is not toxic). So in that case the only two options are to put you to sleep or you to suffer in pain. With the straight local, if they don't get an adequate block, again the option is to go to sleep. In both cases, if they are in the middle of the case, they can't just stop because they have to close what they started. This is why the CRNA wants options. That being said, you have to right to refuse general just as the CRNA has the right to refuse to do your case. It's a Mexican standoff. I don't know what else to tell you other than you need to weigh these decisions in light of the importance of the surgery, the possibility that it might get cancelled, etc., but you have to do what you feel is right for you.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston