Having ACL surgery - any advice?

[McSleepy]

I will be having ACL reconstruction surgery next week and, this being my first ever surgery, I could use all the help I can get. The truth is, I'm quite scared - not because of any real concerns, but because I'm like that. I was trying to convince some of you that I'm a big baby, but you wouldn't believe me (in this thread: viewtopic.php?f=1&t=59128&p=555825). It isn't as much pain that I fear, it is the general anesthesia. Especially after reading about the possibility of anesthesia awareness. I'd sometimes get panic attacks at night when I feel I can't get enough air from my CPAP, so imagine if given enough paralytic/muscle relaxant to inhibit my normal breathing and not enough general anesthetic to keep me unconscious, how I'd feel then. That possibility is why just the thought of not having control (unconscious/helpless) is giving me the creeps.

But, if we have to ignore my fears and stay on more objective topics, I was wondering how SA is affecting our tolerance of general anesthesia. I do have central apneas, even if not fully asleep. During my last sleep study, I couldn't truly fall asleep because they kept me on my back and I still registered 7 apneas, all central. That's being nearly awake (stage N1 and N2 sleep, only), imagine with anesthetic. I know I'll be attached to a ventilator, but I still wonder how it will go. I plan to talk to the anesthesiologist, but if they're anything like the ones who delivered anesthesia to my wife during her surgeries, they spent all of 30 seconds talking to her before disappearing. What should I be watching for and what to do to prepare better? I'd appreciate you sharing your experiences, especially if you had arthroscopic surgery. I wonder if I could ask the anesthesiologist to use a minimum amount of relaxant and not a whole lot of general anesthetic - frankly, I don't care if I'm awake (the knee should get local anesthesia), some people do that surgery on an epidural block. I'm sure I'd be quite calm even observing how they drill through my bones than waking up paralyzed, feeling like I'm suffocating (it is believed that suffocation is the worst feeling one can experience; hence the water-boarding torture).

Anyway, I'll keep this first post short, but hope to get into more detail, depending on the response.

McSleepy

P.S. For those who are curious, I tore both my MCL and ACL (the former heals on its own - in months time) while skiing. The MRI showed those findings, including that, most probably, the meniscus is intact.
MS

[cowlypso]

I've had several surgeries and other anesthesia-related experiences.

I've had 2 ankle surgeries. Both of those I'm sure were done with a similar anesthetic level as a knee surgery would be. I absolutely wanted the general anesthetic because I did not want to be aware at all of the drilling through bone and all. For my first surgery (where they were going to be doing a lot of drilling through bone), the surgeon said that it would be general unless I had a serious objection to that, but they get better results with general because of the deeper muscle relaxation.

For the second surgery (different surgeon, less invasive surgery) I didn't ask the surgeon about anesthesia beforehand. The anesthesiologist walked in that morning and asked if we were doing general or spinal. I was totally caught off-guard, as I had not known that spinal was an option, and hadn't had the chance to research it at all. So I went with the general because it was what I knew.

I also had my gallbladder out, which was deeper anesthesia (rather than just supporting your breathing, like for the other 2 surgeries, they actually put me fully on a ventilator because they need to be able to "hold your breath" for you at certain points).

With all 3 surgeries, I have had absolutely no problems with the anesthesia. Sure, you hear stories about people waking up, but those are incredibly rare. In all 3 surgeries, I remember nothing from the time they put me out until I woke up in recovery. Same with the several endoscopic procedures I've had done. With all of those procedures, I had undiagnosed OSA, and it was never a problem.

So try not to be afraid of the general anesthesia. They are very good at what they do. But if you don't want to go that route, there are alternatives. They can either do a spinal anesthetic or a peripheral nerve block. If you are interested in an alternative, you should talk to your surgeon about it so they can let the anesthesiologist know in advance.

[robysue]

McSleepy,

My newly torn MCL wishes you and your ACL a good surgery and a speedy recovery.

I don't have much to offer other than make sure you talk to the anesthesiologist ahead of time and fully apprise him/her of your apnea, its treatment, and all of your concerns. You may want to specifically ask about whether to bring your PAP machine with you or not. And you should definitely bring up your fears, including your fear of anesthesia awareness and your tendency towards getting panic attacks at night when you feel you can't get enough air from your CPAP.

Since you are worried that you'll only have a quick 30 seconds with the anesthesiologist right before the surgery, why don't you call the surgeon's office and tell the receptionist that you have knee surgery scheduled, but that as a sleep apnea patient you know that the there are concerns about anesthesia and that you want to make sure that the anesthesiologist is fully aware of your medical history and that you'd like to speak to him/her about some of your concerns.

Robysue

[McSleepy]

Thank you, so much, for your response. It does give me an insight from someone who has been through it. And it does make me feel better hearing you had good experiences with your surgeries. Of course, women are so much tougher than men, we are "the weak sex" mentally, even though we won't admit it, so I still need to work on my anxiety. So far I've been advised a couple of hypnotherapy sessions and an anxiolytic the day before. I don't know that I would necessarily panic but I'd better be safe than sorry. It's funny - I have no problem with the ENT burning my turbinate tissue and crushing the bones while I'm fully awake, but the smallest upset to my breathing makes my heart go racing (which, by the way, should be a good indication to the anesthesiologist).
I have an appointment with my surgeon on Monday to discuss the surgery, which should be on Friday. I did bring up spinal but the surgeon seemed to think it wasn't preferable. He mentioned they use a nerve block even with general anesthesia. Maybe I can ask the anesthesiologist to ease on the muscle relaxant since the block and the IV analgesics should take care of all the pain. I'll read up some more and work with the surgeon (I don't think I'll be able to talk to the anesthesiologist until right before the surgery), but I'm aware you can't be 100% prepared for this, I'll have to have faith in the medical professionals. And I do. I've just been around doctors my whole life, I even worked in a cardiac surgery hospital, where I've attended anything from angiographies to open heart surgery, and it ain't pretty, how it all works.
Thanks again for the feedback!
McSleepy

[chunkyfrog]

When I had one surgery, they didn't wait long enough to intubate me; and I let them know about it afterward!

[avi123]

Check here how will it be done:


http://www.yourpracticeonline.com.au/kn ... video.html


But what does it have to do with CPAPs?

[McSleepy]

Robysue, I was writing my previous response when yours came through. Thanks for the advice, I will ask my surgeon on Monday whether I can speak to the anesthesiologist, but I'm afraid, they won't even know who it'll be until the day of the surgery. Each option has upsides and downsides, so far I think I'm leaning (if that is reasonable) to general anesthesia with very little muscle relaxant but with a nerve block and analgesics. Which might very well be what they intend to do, anyway. I'm sure they won't let me suffocate, but sometimes there is latent memories of trauma, even when you are unconscious (hence, possibly, some reports of awareness where the anesthesiologist is certain that the patient was not conscious). It's probably not comparable but even normal sleep involves muscle paralysis and I've experienced that many times: I'd have a nightmare and I'd regain my consciousness a second before regaining muscle control and it'd be an awful feeling when I can't move. Other times I'd wake up horrified (this mostly in the years before I got on CPAP) without knowing why - obviously, something happened in my deep sleep that I don't recollect afterwards. Years of sleep apnea can sure play tricks with your mind and make you anxious when other people will be taking control of your body.

Again, I don't expect any issues but I'd just like to be as prepared as I can be. Imagine how I'd feel if something that could have been avoided comes up, how I'd regret that afterwards. Your input is valuable, thanks again!
McSleepy

[Otter]

I'm scared of general anesthesia too, so I'd go with a spinal block for knee surgery. If your anesthesiologist doesn't discuss option, ask about it.

Either way, they'll probably give you Versed. This is basically a date rape drug. They give it to you so you won't remember the surgery, but some people experience permanent deep retrograde memory loss. A friend who is a physician was one of them, so I know this isn't just a bunch of career victims with no scientific knowledge spinning fantasies. She had to re-learn some things about drugs. She also completely forgot that her daughter had started smoking!

Here's a not very well organized site on the problem:
http://versedbusters.blogspot.com/

I suspect these effects are not as common as VersedBusters claims, but it does happen, and it's something you should be aware of.

After your surgery, rehab is very important. If you follow the instructions and work hard, you'll get the best possible outcome.

Best of luck.

[McSleepy]

Otter, actually, part of my fears are because I observed that effect on my wife after her last surgery (gallbladder): after she was in full consciousness and discharged from the hospital, and we were in the car driving home, she spoke to me about something important, and then that same evening she had absolutely no recollection of it. It seems to be no big deal but I can't help but wonder what else is there. And, frankly, she has been complaining lately of what she jokingly describes as "my Alzheimer's" - she'd get confused (like counting money at the register, or other routine tasks) or forget things she believes she shouldn't have forgotten. She has had 5 surgeries in her life, which is not much - some people have dozens. But I love my "precious mind" so much, I can't help but worry about losing even a tiny piece of it.
McSleepy

[Otter]

This is exactly why I'm afraid of general anesthesia, McSleepy. Though it turns out that some of the effects I observed in the people I love were probably caused by Versed rather than GA.

If you elect to not have Versed and get a spinal block, I think odds are good that you'll emerge with your brain intact -- or at least as intact as it was before surgery.

They might want to give you diazepam (Vallium) if you refuse Versed. I have not researched high doses of this drug, but I think it's probably a lot safer. You may want to find out who your anesthesiologist will be and discuss your options well ahead of your surgery so you can do your homework. If he can't be bothered to talk with you on the phone for 15 min, insist on an anesthesiologist who will talk to you!

[pap4life]

Mc...I think you will be just fine with the general anesthesia.
I had hand surgery last year and they/we opted for general anesthesia. They offered me something (nerve block) of some sort, but I said I wanted out, as in "lights out". Wake me when its over!! I wanted no looking, seeing or feeling anything. Everything worked out just fine.

Lots of folks get some residual anesthesia memory effects. After my surgery, wife and I were on the way home and I wanted to stop and shop for a roast for making a pot roast. So we went shopping. Next day I opened the fridge and said: where did that meat come from?
Didn't remember shopping, although I remember being discharged and leaving the hospital ..
Just advise the Anesthesiologist you are a CPAP user and all will be fine.

[ohwhatanight]

Sorry about your ACL. I trashed my knee, gastroc muscle and ankle about 10 years ago with a fall on ice so I can sympathize. The good news is ACL surgery is usually very successful and can give you your life back pretty quickly. I found a message board back then that was incredibly useful helping me prepare mentally and physcially for the surgery. A quick search found it is still around after all these years. http://factotem.org/cgi-bin/kneebbs.pl

For lots of non-related medical reasons, I've had general anesthesia many times. I actually don't mind it at all or fear the breathing part because I know I am in really good hands, hooked up to a ton of monitors and I have someone completely dedicated to watching my breathing, oxygen level, heart rate, etc the whole time. You will probably be taken care of better during the surgery than you are on your CPAP at home and you will get a really wonderful nap! (I used to joke that I looked forward to general anesthesia because it was the only time I slept really really well!)

I do make a point of telling the nurse as soon as I arrive for any procedure that I want to talk to the anesthesiologist about several concerns. That way they make sure I don't get the 5 second "meet & greet" but actually have time to talk to him. I have a lot of problems with nausea when I wake up from generals - after several explosive vomiting episodes, I know to ask for really strong cocktail of anti-nausea meds before surgery. Also, if possible, I ask for a nerve block or strong local near the end of the surgery even if they are doing a general so I don't wake up in uncontrollable pain. Usually they are happy to oblige. If you have a lot of anxiety about the surgery, you can ask for something for that as well while you are waiting. They are usually happy to give you that too.

[Otter]

Lots of folks get some residual anesthesia memory effects. After my surgery, wife and I were on the way home and I wanted to stop and shop for a roast for making a pot roast. So we went shopping. Next day I opened the fridge and said: where did that meat come from?

That sort of memory loss is expected. But when people don't remember significant details of their lives before surgery, or have to relearn basic professional knowledge, that's another thing entirely.

[Otter]

McSleepy, another thing to keep in mind is that typical post-op meds and apnea can be a dangerous combination. This is enough of a danger that some hospitals now screen all surgical candidates for OSA before surgery. OTOH, when my mother had her shoulder replaced, the nurses at our local hospital didn't bother to help her put her mask on, even after I discussed this with them at length and they promised to alter their schedule so she didn't have to take the mask off and on several times during the night. (Mom has aphasia from a stroke, so it's difficult for her to argue about such things.) Whether they send you home or keep you for a night or two after your surgery, use your machine. And if you need help with anything CPAP related, don't take no for an answer!

[McSleepy]

Thank you, thank you all, for your advice, references and comments!
Yes, the effect of the drugs during and after surgery (anesthetics, sedatives, analgesics, relaxants) can affect the sleep on the next night. My surgery will be outpatient, so I'll be home that same night. Because of the knee, I can't imagine a very comfortable sleep (I can't sleep but on m y stomach). I'll probably be forced to sleep on my back for at least a few nights, and that's when I have central apneas. I don't think any change in my machine settings would help - higher pressure is considered conducive to central apneas; being on my back, I'd probably have to reduce the pressure a bit, if anything (not to mention all the aerophagia I get if I'm not on my stomach, even for a few minutes, at 9.6/15 cm H2O). I should probably talk to my sleep doctor, but I don't know that he'll be able to say much. I actually have two: the ENT, who prescribed the last sleep study, and then I saw a dedicated sleep doctor (that's all he does), but the latter didn't have much to say when I saw him.
I've had three CPAP machines (all bi-level) and they all had alarms for mask events; I wish they had alarms for lengthy apneas - at least my wife would wake up and help me!
McSleepy