An Introduction To Anesthesia

Why Does One Need Anesthesia?
One would think that it is just to stop pain.  Not only is it immobility of the patient as well as pain relief it has to do with control.  Control of  your body and its defense mechanisms having to do with pain.   Although you can tell the difference between a safe, elected incision and an accidental skin trauma like a cut or a stab wound.  Your body, essentially, can not.  You see, as soon as your body is cut or manipulated, your body goes to work.  Your heart rate quickens, your body starts to try and repair the injury with a vengeance.  Well, anesthesia blocks this reaction until after the surgery is over and keeps your body from trying to overwork itself intra-operatively (during surgery).  It also helps you forget about your surgery.  Surgery can be very traumatic for some so why suffer?  Healing is better and faster when one does not realize or remembers pain.

How Does Anesthesia Work?
There are hypotheses and then there are facts.  The facts are that anesthetics are dependent upon your body fat, weight and the strengths or concentrations themselves regarding duration and effectiveness.  Also some patients have a higher tolerance in general than the next.  All this must be taken into account by the anesthesiologist to safely administer and maintain a pain-free state of unconsciousness.

Anesthesia works in 5 ways:

1. analgesic (pain reliever)
2. amnesiac (loss of memory)
3. promotes unconsciousness
4. immobility of the patient
5. elimination (or reduction) of autonomic responses such as tachycardia (increased heartbeat), increased breathing, hypertension, lacrimation (tear production)

The obstruction of sensory, reflex, mental and motor functions are needed to safely and effectively operate on a patient.  There are gaseous and liquid General anesthetics or a combination of both agents can be used.  Ascertain that your anesthesiologist is fully qualified and fully certified or at minimum, a CRNA, to safely administer anesthesia to you.  This is very important.  However for some types of anesthesia such as versed and fentanyl whereas light sedation is used, most surgeons believe there is no need for an actual anesthesiologist, just an OR tech who repeatedly says your name over and over to make sure you are under completely as well as monitors your heart rate, blood pressure, etc.  Everyone will have a different opinion about this so be sure to research and determine what makes you feel safe.  Ideally, a doctor of anesthesiology might be considered safest, but there are no fool proof scenarios.

These factors are what makes it possible for anesthesia to work.  This information has been provided for you so you won't feel overwhelmed when you discuss anesthesia with your surgeon.

Your Choices In Anesthesia
There are a few choices that you may have for anesthesia although not all surgeons and their practices will offer every one. 

The four main categories of anesthesia are:

• local anesthesia
• regional anesthesia (nerve blocks)
• sedation 
• general (deep) anesthesia 

Local Anesthesia
Local anesthetics are what you have when you receive a shot to numb the immediate treatment area. You most commonly receive local at the dentist's office but also receive it during a rhinoplasty or other type of surgery in addition to Sedation. 

The injection is most commonly of Lidocaine (or Xylocaine, Marcaine), epinephrine (as a vasoconstrictor to impede bleeding in the treatment area and absorption of the Lidocaine by the patient) and sometimes sodium bicarbonate as a buffering agent.  Injections of anesthetic are thought to block nerve impulses by decreasing the permeability (think of  microscopic openings for the impulses to leak through) of nerve membranes to sodium ions.  There are many different local anesthetics that differ in absorption, toxicity, and duration of action.  There is a possibility of Lidocaine Toxicity  which we will discuss later on.

What Does Local Feel Like?
I have had local many times, mostly for lip augmentation procedures, in the E.R. for non-cosmetic reasons, in the dentist's chair--you name it.  It feels like a typical shot, like a pin prick.  It burns a little as it is going in and then it starts to take effect.  The treatment area feels very numb and it may feel like it is twice the size as normal.  It begins to wear off within an hour or more, depending upon the dose.  When feeling returns, it may feel tingly, almost like when your arm or foot "falls asleep."  This may feel slightly uncomfortable but it does wear off quickly after that.  Multiple local injections are used during surgery, right before your first incision.  

EMLA Creams and Topical Liquids (Considered Local)
You can also obtain the benefits of local anesthesia by using a topical agent, or ectatic mixture of local anesthetics (EMLA) cream which contains lidocaine and prilocaine to numb the mucus membranes or broken skin area before a procedure such as injectable fillers, micropigmentation or other minimally invasive procedures.  The white EMLA cream is applied and covered and then an hour must go by before undergoing the procedure for optimum anesthetic effects.  For some procedures it is more of a hassle to anesthetize with an EMLA than to stand the pain itself.  Believe it or not, sometimes brain surgery is performed under Local anesthesia (to the scalp) so that the patient can be awake to assist the surgeon when a specific cut or correction is made -- testing for the existence of senses after a certain move, etc. 

However, EMLA may now be moved aside as you can now get Ela-Max.  It is cheaper, available over the counter (OTC), faster and doesn't have to be occluded (covered and packed against the skin).  Ela-Max contains 4% Lidocaine and is making it's way to a surgeon near you.

What Does Topical Local (EMLA) Feel Like?
There are topical liquid anesthetics and creams. I have had both topical anesthetics a few times.  EMLA feels like a typical cream going on and is for non-broken skin.  Liquids are for mucosal linings and broken skin.  Once the cream is applied it may feel cold for a while, when it works the treatment area will feel numb.  The cream is removed right before the procedure and will start wearing off now that there is no anesthetic present.  Once the skin is broken, a topical liquid anesthetic can be applied.  EMLAs do not last very long in my opinion.  Using EMLA creams or topical liquids can be used for chin augmentation only if you are getting injections and not implants.

Regional anesthesia
Regional anesthesia was named such because a region of the body is anesthetized without rendering the patient unconscious.  For instance, spinal anesthesia for childbirth.  Do not get this confused with an epidural as they are very similar in effects but a different locale is injected with the anesthetic.  In an epidural the injection is in the area outside the spinal fluid called the epidural space, the catheter is placed inside this area so that anesthetic injections may be given or can be tube-fed if needed for longer periods of time (from hours to weeks).  With spinal anesthesia, the local anesthetic is injected into the spinal fluid that causes a loss of sensation to the areas below the navel.  Also, in spinal anesthesia, such narcotics as morphine and fentanyl can be infused in addition to or partially substituting the anesthesia.  But since regional blocks in plastic surgery do not often involve spinal anesthesia (except in some tummy tucks and lower body liposuction), we won't be covering this.  Rather will will cover regional anesthesia of the face as some facial surgeries can be and are routinely performed while under this type of anesthesia.  Such as brow lift touch ups, lip reduction and augmentation surgeries, chemical peels, sub-mental liposuction and more.

You may have also heard them referred to as nerve blocks.  A nerve block is considered regional as an anesthetic is injected into a nerve cluster and it effects sensation in all areas which this cluster controls. There are nerve clusters all of your body; for instance, under the jaw, in the chin, and under the eye.  They sometimes feel like little holes in the bone where your nerves are clustered, then branch out to the different areas of the face or anywhere on the body. 

What Does Regional Anesthesia Feel Like?
I have had regional several times and it feels like a typical shot but into a nerve cluster.  Sometimes when the needle strikes a nerve you will feel a title jolt or shock.  It can be uncomfortable but it works very fast this way and you need less injections than with typical local anesthetic.  Regional anesthesia is usually not utilized in chin augmentation surgery, but is used for chin augmentation with injectables and even with the Feather Lift (APTOS threads) procedure.

Sedation (Oral, Gaseous and IV)
Sedation can be gas, oral or intra-venous (IV). Most common are liquids such as Versed.  This is where a sedative such as Valium may be given ahead of time as well as a liquid formulation for the main event , a catheter is inserted into the vein of the hand or arm and a mixture of saline (as a carrier), Versed and DIPRIVAN or Ketamine and a few other additives for a nice sedative cocktail.  They can customize the concoction specifically for the patient.  You are usually given Sedation with Local as well. The Sedation helps with the anesthetic properties -- ease of mind, loss of memory, rendering unconscious, etc. with the benefits of Local for pain relief after you awaken, lessening of autonomic functions and epinephrine for impediment of bleeding (which can also lead to bruising) intra-operatively.

You may have had laughing gas (or nitrous oxide) before for dental work or OBGYN matters.  It is an inhaled gas, actually low doses of the same type of gases for General anesthesia, that incorporate the pain relief, the amnesiac properties as well as the other 3 that are important in invasive surgery but are not as strong so a sedative or local or even regional may be administered as well.  The good thing about nitrous oxide is when they take the mask off, you are back to normal a few minutes later but still with no pain if you had the local anesthetic as well, which is more probable than not.

A few liquid anesthetics like the Versed and Ketamine can be taken orally, but some can be inserted via the rectum with a small lubricated tube or even inhaled like a nasal spray. 

What Does Liquid IV Sedation Feel Like?
If you had been given an oral sedative or valium prior you usually could care less what they are sticking in you.  Regardless if you have IV or gas they will more than likely insert an IV for a saline drip to keep you hydrated and have a vascular doorway should the need arise.  If you haven't been given a sedative, it is more stressful for some patients.  Having an IV inserted feels sort of like blood being drawn, but for a shorter period of time.  It's the initial placement of the IV catheter that may sting a bit.  After the needle is injected into the vein it is pulled out and a little plastic tube is left in your vein.  This is called a catheter, which is taped to your skin so it is not knocked out and is ready to be used as a sort of entryway for anything they deem suitable for your body.  This is usually done before you get into the actual O.R. (by a nurse) and you have a saline bag hooked up to you.  The medications will be given with a drip system with this saline.  As I said, the saline will keep you hydrated both during and post-operatively. Some people get their catheter in the crook of the elbow, some the hand.  I dislike the ones in the hand as it's a nasty place for a bruise to be, at least with the arm you can hide it, it all depends upon your veins though.  So if your veins are not very prominent this can be a problem.  Some patients even have to be catheterized in the leg.  

After you are properly catheterized and your vitals are stable and normal, the anesthesiologist will insert a hypodermic into your tube that you are attached to or more than likely they will attach a bag of anesthetic with a drip system to add a few drops every few seconds or so.  When they spring open the stopper and it starts heading towards your body.  The effects of the anesthesia are felt soon after injection or opening the stopper, a few seconds in fact.  It may feel like heat going into you veins then creeping up your arm; then it feels as though it jumps from your shoulder to a metallic-like taste under your tongue and then you are blissfully anesthetized.  I have had several forms of IV sedation and actually prefer it.

Liquid IV sedation is commonly utilized for chin augmentation surgery.

What Does Light Gaseous Sedation Feel Like?
If you have chosen light, gaseous anesthesia all this entails is breathing through a mask as far as you remember.  Typical mask delivered anesthetics are commonly utilized for very short procedures or very light sedation--think dental, gynecological, etc. However with adequate local anesthetics and light gaseous sedation, a chin augmentation procedure can be performed when the incisions are extra-oral.  But light, gaseous sedation is often not the chosen form of anesthesia for this procedure.

Regardless of the type, you basically are told to count down from 100, and see how far you can make it, usually 97 or 96.  After the gas hits the aveoli in your lungs, your blood is saturated by the anesthesia gases where they are carried to your central nervous system (CNS) where you are in all actuality, knocked out.

You may wake up with a slightly raw throat.  You may wake up with a sore, dry throat regardless because canned or cylinder air (scubadiving tanks as well) is very dry.  There is no moisture in these tanks.  It is your turbinate structure (three little fleshy flaps in your sinuses) inside your nasal structure that mostly warms and humidifies the air which you breathe.  

Light Gaseous sedation is commonly utilized for chin augmentation surgery.

What Does Oral Sedation Feel Like?
Oral sedation is basically taking a sedative such as Valium (diazepam) or Xanax (alprazolam) by mouth an hour to an hour and a half before a procedure.  Oral sedatives make you very calm, drowsy and you may even fall asleep depending upon the dosage.  Many times you are allowed to have an oral sedative before a procedure with standard anesthesia.  It takes the edge off of the anxiety you may feel the night before and morning of your operation.

When you take the sedative either by swallowing or sublingually (holding it under the tongue to dissolve) as long as you can, and anywhere from 20 minutes to an hour from taking the sedative you will feel its effects.  You often feel calm, your balance may be affected, you may feel very peaceful and as said before, may simply fall into a light sleep.

Light Gaseous sedation is commonly utilized for chin augmentation surgery.

General Anesthesia (Gaseous)
General can be given by an inhaled gas or by an IV liquid, or both simultaneously. General isn't fully understood, yet. But they speculate that it works in several ways:

• neuromuscular blocking agents which effect the spinal cord (resulting in immobility of the patient)
• "brain-stem reticular activating system" (resulting in unconsciousness) 
• cerebral cortex (as seen as changes in electrical activity on an electroencephalogram)
• Inhalational agents to control autonomic responses and provide analgesia and amnesia
   (or)
• Benzodiazepines (such as Valium, my preference) for their anti-anxiety and amnesiac effects
• obstruction of nerve conduction
• interruption of synaptic transmission (It is more difficult to explain synapses interruption, so take my word for it - I don't even remotely understand it yet.)

Total Intravenous Anesthesia (or TIVA) is intravenous sedation only, it's what I prefer with Light Sleep IV sedation.  This is also done without a TCI pump and this is when the anesthesiologist calculates the needed dosage by skill and experience with the weight factors, other medications present and also by careful monitoring of the patient's vitals.

What Does General Gaseous Sedation Feel Like?
If you have chosen Gaseous-state General anesthesia, what you remember depends upon the anesthesiologist's preferences.  If your anesthesiologist prefers IV sedation before hand, you will only remember the experience outlined above in the "What Does Liquid IV Sedation Feel Like?" section.  If your anesthesiologist prefers gaseous sedation beforehand all this entails is breathing through a mask as far as you remember.  After you are lightly sedated, the intubation begins...

The newer intubation (LMA) is basically like the older intubation for General but there is a shorter tube and a little balloon the size of your two thumbs which holds your tongue and throat tissues out of the way so it does not obstruct your breathing.  I have had LMA before and I don't remember a thing.  The sedated me with an IV anesthetic and then while I was knocked out, they intubated me.

With the older intubation you have the pleasure of having a longer tube down your throat but you don't remember it going in as you are usually temporarily anesthetized with IV sedation or gaseous sedation as outlined above.  After the seal is made with the tube, and only after your oxygen saturation is satisfactory and your vitals are determined as stable, other medications may be given.  The anesthetic gas saturation may be increased and other modifications may be made.

Cautionary Note: Also be advised that if you have bronchospasm, asthma or other disorders such as this, intubation is contraindicated unless prior adjustments have been taken; pre-medication may be one of these.  Please make sure you read the risks associated with Anesthesia, below.  

Twilight (or Laughing Gas) (basically a weak form of General) can be given via a mask as well, with no intubation.  I have had this as well and find it to be really mild and fast acting.  The good thing about this is that as soon as they remove the mask you start waking up or coming to.

General Gaseous sedation is commonly utilized for chin augmentation surgery. 

Why Shouldn't I Eat Before Surgery?
You are often told not to eat past midnight the night before your surgery but perhaps only a few sips of water (of course of your surgery is scheduled for the morning).  To better explain this to you, this is best said by the American Society of Anesthesiologists Guidelines on Sedation and analgesia by Non-Anesthesiologists.

Example of Fasting Protocol for Sedation and Analgesia for Elective Procedures:

Gastric emptying may be influenced by many factors, including anxiety, pain, abnormal autonomic function (e.g., diabetes), pregnancy, and mechanical obstruction.  Therefore, the suggestions listed do not guarantee that complete gastric emptying has occurred.  Unless contraindicated, pediatric patients should be offered clear liquids only up until 2 to 3 hours before sedation to minimize the risk of dehydration.

age	Solids and Nonclear Liquids*	Clear Liquids
Adults	6 to 8 h or none after midnight1	2 to 3 h
Children older than 36 months	6 to 8 h	2 to 3 h
Children aged 6 to 36 months	6 h	2 to 3 h
Children younger than 6 months	4 to 6 h	2 h

* This includes milk, formula, and breast milk (high fat content may delay gastric emptying).
¹ There are no data to establish whether a 6 to 8 h fast is equivalent to an overnight fast before sedation/analgesia. American Society of Anesthesiologists Guidelines on Sedation and analgesia by Non-Anesthesiologists, source: www.GasNet.org

Your Anesthesiologist
If you are going under General deep sedation, it is best to choose a surgeon who will have a separate anesthesiologist, this is important.  The anesthesiologist basically must know for your weight and body fat percentage what will work best for you and in what amounts plus they monitor your heart rate, breathing rate, your blood pressure, etc. and stand there and say your name over and over so that if you answer or your vitals change during the course of the surgery, or even if you stir, they know you aren't getting enough anesthesia.  

If you are going under light sleep (IV or Gas) a separate anesthesiologist may not be present in some O.R.'s.  Some use CRNA's, in others the surgeon may be in charge of it.  The amount of anesthetic is determined per your individual body weight with anesthetic to body-ounce formulations and fed via a drip system mixed with your IV saline.  Personal tolerances are also taken into account.  However, any reactions by the body while under anesthesia should be monitored closely by a highly qualified individual.

To become an anesthesiologist, a person must complete:

• college

• medical school

• internship

• three-year anesthesiology residency

Recovery From Anesthesia
This is very important.  Many things can go wrong during initial recovery.  The shivering and feeling cold is the least of your worries.  Please read the below information and discuss the regarding your surgeon's anesthesia protocol.

• "Patients must be monitored during recovery to ensure that any adverse events are rapidly recognized and treated.
• Vital signs should be recorded at regular intervals and pulse oximetry should be continued until the patient is no longer at risk of hypoxemia.
• Monitoring should include observation by a person trained in recognition of post-procedure/post-sedation complications.
• Appropriate discharge criteria should be met prior to discharge.

When I begin to regain consciousness I feel very cloudy like my peripheral vision is gone temporarily and everything is of a white, blanched hue.  I get emotional sometimes and this is very normal.  Some patient cry, some are immediately back to normal but most report a sluggish feeling in their limbs and this will pass.  You may think that you didn't even have your surgery because it feels as if you just went to sleep 5 minutes beforehand.

Some patients may become nauseated so alert one of the nurses if this is so.  He or she can give you a few sips of cool water to help stave the nausea or at least provide you with a receptacle in which to vomit.  You probably won't be given fluids just yet, more than likely just ice chips until you are no longer feeling nauseated.  Some surgeons have you take an anti-nausea medication such as Zofran to decrease your risks of vomiting after your surgery.  I forgot to take mine so I got sick twice right after surgery.  Zofran is pretty expensive but it is worth it if you don't want to get sick.

Some patients begin shivering so if you feel a little chilly, let the recovery room nurse know so he or she can give you a warm blanket.

Risks, Contraindications & Complications of Anesthesia
Causes of anesthesia-related death are usually linked to the respiratory system.  These include insufficient intubation or proper ventilation which results in hypoxia, which is a deficiency of oxygen reaching the tissues of the body.  Below is just a partial list of the possible risks and complications related to anesthesia.  

Complications are mostly related to General Gaseous-state anesthesia and may include laryngospasm, bronchospasm, aspiration, intubation injury, pulmonary edema, respiratory arrest. Cardiovascular complications may include myocardial ischemia/infarction, myocardial ischemia, myocardial infarction, cardiac failure, cardiac arrest, hypotension.

Lidocaine Toxicity:
Lidocaine toxicity is something that can occur with way too many injections of Lidocaine. A common procedure requiring vast amounts of Lidocaine is Tumescent and Super-Wet Technique Liposuction.

"- Pre-existing cardiac or pulmonary disease may require reduced dosage because sedative and analgesic medications tend to cause cardiovascular and respiratory depression.

- Hepatic and renal abnormalities may impair drug metabolism and excretion resulting in longer duration of drug action." Adapted from the American Society of Anesthesiologists
Guidelines on Sedation and analgesia by Non-Anesthesiologists, source: www.GasNet.org

Smoking Tobacco & Illegal Substances

"- Smoking increases risk of airway irritability, bronchospasm, or cough during sedation. "Adapted from the American Society of Anesthesiologists
Guidelines on Sedation and analgesia by Non-Anesthesiologists, source: www.GasNet.org

Medication and Supplement Contraindications Regarding Anesthesia
There are some medications and supplements that you simply should not be consuming before and after going under anesthesia, although this may be a partial list PLEASE talk this over with your surgeon!!!  

THIS IS A PARTIAL LIST

• Ginseng may cause rapid heartbeat/and or high blood pressure in some individuals.
• St. John's Wort, Yohimbe, ("The natural Viagra") and Licorice root have a mild monoamine oxidase (MAO) inhibitory effect and may intensify the effects of anesthesia. (*note some well known and popular anti-depressants are MAO inhibitors, disclose any and all medications you are taking -- your life may depend on it!)
• Melatonin decreases the amount of anesthesia needed for surgery.
• Echinacea may have a severe impact on the liver when general anesthesia is used.  Please advise your surgeon of all medications and supplements and alert him to the possible effects of herbal supplements and remedies, he may not be aware of the contraindications.
    

Special Medication Alerts
If you are on Anti-depressants, please advise your doctor.  Some monoamine oxidase (MAO) inhibitors (also known as MAOI) intensify the effects of the anesthesia -- especially General.  This could be quite dangerous in the operating room if your doctor is unaware of your medication usage.  If you advise your doctor he or she can make adjustments for your anesthesia or at least will watch for the slightest decrease in heart or breathing rate.

These medications may include: Isocarboxazid, Marplan, phenelzine (Nardil, Nardelzine)
tranylcypromine (Parnate, Sicoton), Deprenyl, selegiline hydrochloride.  They are used for the treatment of depression, obsessive-compulsive disorder, eating disorders, essential hypertension (pargyline), chronic pain syndromes, and migraine headaches.  They work by inhibiting nerve transmissions in brain that may cause depression.  Tranylcypromine and phenelzine account for over 90% of all MAO inhibitors currently prescribed. 

It is reported that drug interactions can occur even weeks after discontinued use of an MAOI.  Therefore, in patients undergoing General anesthesia, cessation of usage is normally instructed several weeks prior to surgery to avoid possible cardiovascular effects.  Although, I know of several patients who never were instructed to cease their medications and were perfectly fine.

"Anesthetic Requirements: Anesthetic requirements are increased, reflecting accumulation of norepinephrine in the CNS." Ref: Stoelting, R.K, Pharmacology & Physiology in Anesthetic Practice, pp. 378-381.

In Conclusion
The above information is not meant to scare you but rather to inform you so that you are able to make a well-educated decision regarding your anesthesia choice.  Remember, thousands of people undergo anesthesia safely every day.  Please don't let anesthesia be the factor that kept you from having your surgery -- just know that these complications are possible.  

The Least You Need To Know

• As soon as your body is cut or manipulated your body goes to work.  Your heart rate quickens, your body starts to try and repair the injury with a vengeance.  Well, anesthesia blocks this reaction until after the surgery is over and keeps your body from trying to overwork itself intra-operatively (during surgery). 

• Anesthesia also helps you forget about your surgery.  Surgery can be very traumatic for some so why suffer, correct?  Healing is better and faster when one does not feel or remember pain.

• Anesthesia works in 5 ways:

  1. analgesic (pain reliever)

  2. amnesiac (loss of memory)

  3. promotes unconsciousness

  4. immobility of the patient

  5. elimination (or reduction) of autonomic responses such as tachycardia (increased heartbeat), increased breathing, hypertension, lacrimation (tear production)

• The obstruction of sensory, reflex, mental and motor functions are needed to safely and effectively operate on a patient. 

• There are a few choices that you may have for anesthesia although not all surgeons and their practices will offer every one.

• The four main categories of anesthesia are:

  • local anesthesia

  • regional anesthesia 

  • sedation 

  • general anesthesia 

• General Anesthesia can be given by an inhaled gas or by an intravenous liquid. 

• Liquid Sedation can be given by injection or some even by oral drops.

• Choose a certified Anesthesiologist when going under deep General sedation.  This may cost more to have a separate anesthesiologist but it is considered safer by many.

• To become an anesthesiologist, a person must complete:

  • college

  • medical school

  • internship

  • three-year anesthesiology residency

• There are some medications and supplements that you simply should not be consuming before and after going under anesthesia, although the above list may be a partial list PLEASE talk this over with your surgeon.

• KNOW THE RISKS

• Do realize that thousands of patients safely go under every day and that these risks, although possible, are rare.

Online Anesthesia Textbooks
Anesthesiology Textbook - Yale  
GASNet - An Online Anesthesia Network
Virtual Anaesthesia Textbook Home Page 

Related Links (all links leading out of the site launch a new window)
American Board of Anesthesiology 
American Association of Nurse Anesthetists 
Anaesthesia On-Line - UK 
Anesthesia Patient Safety  
General Anesthesia in Plastic Surgery - Emedicine
Anesthesia: Local with Sedation - Emedicine
 

References:
Yale Medical Core Curriculum - Yale Medical University
Ovassapian A, Schrader SG. Fiberoptic-aided bronchial intubation. Sem Anesth 6:133-142, 1987.
Stoelting, R.K, Pharmacology & Physiology in Anesthetic Practice, pp. 378-381.
Merriam-Webster Medical Dictionary
J Bergsbaken, University of Wisconsin, Pulseless Electrical Activity"
Virtual Anesthesia Textbook
D. John Doyle MD PhD FRCPC Department of Anaesthesia, The Toronto Hospital
Diagrams, Henry Gray - Anatomy of the Human Body
American Academy of Pediatrics, The Transfer of Drugs and Other Chemicals Into Human Milk (RE9403) Pediatrics - Volume 93, Number 1 January, 1994, p 137-150
 

*drug interactions: "Induction dose requirements of DIPRIVAN may be reduced in patients with IM or IV premedication, particularly with narcotics (eg, morphine, meperidine, and fentanyl, etc) and combinations of opioids and sedatives (eg, benzodiazepines, barbiturates, chloral hydrate, droperidol, etc). These agents may increase the anesthetic effect of DIPRIVAN Injectable Emulsion and may also result in more pronounced decreases in systolic, diastolic, and mean arterial pressures and cardiac output. During maintenance, the rate of DIPRIVAN administration should be adjusted to the desired level of anesthesia and may be reduced in the presence of supplemental analgesic agents (eg, nitrous oxide or opioids). The concurrent administration of potent inhalational agents (eg, isoflurane, enflurane, and halothane) during maintenance with DIPRIVAN has not been extensively evaluated. These inhalational agents can also be expected to increase the anesthetic and cardiorespiratory effects of DIPRIVAN. DIPRIVAN does not cause a clinically significant change in onset, intensity, or duration of action of the commonly used neuromuscular blocking agents (eg, succinylcholine and nondepolarizing muscle relaxants). No significant adverse interactions with commonly used premedications or drugs used during anesthesia (including a range of muscle relaxants, inhalational agents, analgesic agents, and local anesthetic agents) have been observed when used in recommended dosages". http://www.diprivan.com

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