Trying to decide on a suitable anaesthetic

When and why is a spinal anaesthetic used over and above a general?

Q I have arthritis of my knee and am going to have a knee replacement after Christmas. My surgeon spoke to me about the anaesthetic and mentioned that a spinal anaesthetic would be best. I think that I would prefer to be asleep with a general anaesthetic. What is the difference between a general and a spinal anaesthetic?

AA general anaesthetic is where you are kept unconscious and pain free during an operation using a combination of drugs. Most commonly these drugs are injected into a vein and you fall asleep after about 15 seconds.

A breathing tube will then be placed in your windpipe and you will be kept asleep for the duration of your operation by a combination of oxygen, air and anaesthetic gases delivered by a mechanical ventilator.

Once the operation is over, the anaesthetic gases are stopped and as you wake up the tube is removed to allow you to breathe normally again. Traditionally, this is what patients expect when they have an operation and it is very safe.

Minor common side effects are drowsiness, nausea and vomiting, and occasional confusion, which can be more pronounced in the elderly. There tends to be a higher incidence of postoperative complications in patients with chronic lung disease, heavy smokers and obese patients.

This group of patients may be better off having a regional blockade if the surgical site is amenable to this type of anaesthetic.

An alternative to a general anaesthetic is regional anaesthesia and these are mostly given as spinal blocks. This type of anaesthetic is especially suitable for patients having surgery on parts of the body below the umbilicus (belly button).

Operations on the prostate gland, hip operations, leg operations, hernias, Caesarean section and even hysterectomy are very suitable for spinal anaesthesia.

Using a very fine needle a small amount of anaesthetic drug is injected into the fluid surrounding the spinal cord and effectively this blocks all pain signals reaching your brain below that level for more than two hours. It also affects movement so your legs will not move until the anaesthetic wears off.

The potential benefits of spinal anaesthesia are better pain relief and less nausea in the immediate postoperative and a quicker return to eating and drinking.

A spinal anaesthetic allows the area that is being operated on to be isolated from the upper body and patients can remain awake although many are given light sedation and effectively have little recall.

In the elderly, obese patients or patients with respiratory disease most anaesthetists would consider this type of anaesthetic preferable to a general anaesthetic. Although side effects are not common, some patients may experience a bad headache a few days after the procedure, which generally resolves within a few days.

During both these operations you will have a doctor who specialises in anaesthesia looking after you. You will be continually monitored during the operation and your safety is the responsibility of the consultant anaesthetist who is looking after you.

Prior to your surgery you will have the opportunity to discuss your preference with both your surgeon and anaesthetist and they will advise you on the most suitable anaesthetic for you.

Q I recently attended a sexually transmitted infection clinic and was very impressed with the way I was looked after. I feel that a lot of men are not aware that this service is available. I was amazed about this and wondered how we could improve the awareness of the importance of sexual health.

ASexual health in men in Ireland is under- addressed. Many men (and women) overlook the serious direct and indirect consequences that relate to sexual health. Some conditions are specific to men, but many are intrinsically related to sexual and general health in both men and women. Sexually transmitted infections (STIs) can cause a lot of health problems with a direct economic burden as well as psychological sequelae.

Most recent provisional data from the Health Protection Surveillance Centre reports STI notification rates in men of 58.5 per cent. Many men have a low awareness of the concept of sexual health, where services are available and are often reluctant to use them.

The risk of both the acquisition and transmission of HIV is greatly increased when another STI is present in either partner. Serious systemic illnesses such as syphilis can have life-threatening complications.

Recurring genital conditions such as herpes or genital warts place direct physical and emotional strain on the patient, take up health resources, and for herpes are a cause of considerable days lost in the workplace.

A service well structured to deal with sexual health in men, as for women, can lead to health improvements, economic gain to society and removal of stigma. It is obvious that we need to improve access to and the use of sexual health services for men.

Recent recommendations outlined by a HSE study include the need for better sex education for young people, better public awareness of sexual health services, especially directed at men, better training of sexual health professionals in men’s health issues, and increasing men’s access to condoms.

In its broader definition, sexual health will need to be more holistic in its approach and not purely infection- focused. It is hoped that greater awareness will lead to less stigma and more health-seeking behaviour from men.

• This weekly column is edited by Thomas Lynch, consultant urological surgeon, St James's Hospital, Dublin with a contribution from Dr Carl Fagan, consultant anaesthetist, St James's Hospital, Dublin, and Dr Colm Bergin, consultant in infectious diseases, St James's Hospital