I read research all the time. For research projects, for courses I’m teaching, or because I have what I like to call a fever dream of an idea and suddenly I’m down a rabbit hole trying to understand why some people like to drink water more than others.

This series is my way of keeping myself accountable and up to date — for my own work, for my students, and for the profession. Each week, I’ll pull out 10 papers worth knowing about: one you really shouldn’t miss, and nine more to check out if you have time.

Most will be anesthesia, with some nursing, medicine, and whatever else is too interesting to leave out. I’ll tell you what the studies found, what they actually mean, where the limitations are, and give you some backstory on the researchers and the work they are doing.

My hope is that you leave knowing a little more, feeling a little less intimidated by research, and maybe with a new fever dream of a question yourself.

And send me what you’re reading. If a paper made you stop, reply or leave it in the comments. And if you published something you’re proud of, send that too — I would love to highlight your work here.

This first edition is open to everyone. Starting next week, the one paper you can’t miss will stay free, and paid subscribers will get the full 10.

Okay. Here is what caught my attention this week!

If you read one thing this week: children can safely drink an hour before surgery

Most parents still hear some version of “nothing after midnight” before their child has surgery.

I want to show you this week’s paper on that rule, and then a paper from 1990.

The new paper comes from researchers at Sri Ramachandra Institute in Chennai, India. They randomized 140 healthy children, ages 1 to 12, to drink either water or a 10% glucose drink, then wait one or two hours before surgery. The trial was double-blind — neither the families nor the person measuring knew who drank what. Blinding keeps hope from leaking into results.

Right before anesthesia, they measured what was left in each child’s stomach with gastric ultrasound (Paediatr Anaesth).

What they found

• The most fluid was in children who drank glucose one hour before surgery: 0.947 mL/kg.

• The least: water with a two-hour wait, 0.268 mL/kg.

• No child in any group crossed 1.5 mL/kg, the conventional cutoff for a “full” stomach.

• There were no aspiration events.

• The children who drank an hour before were more comfortable: 8.31 vs. 6.66 out of 10.

So drinking closer to surgery leaves a little more behind. No surprise — researchers have watched clear fluid leave children’s stomachs on MRI, half-life about 26 minutes (Br J Anaesth). By an hour, most of a small drink is gone. And “a little more” never reached the amount we worry about.

Why one study is never the whole answer

Here is the research lesson in this paper.

A 140-child trial can measure stomachs. It cannot tell you about aspiration — stomach contents getting into the lungs — because aspiration is so rare that no single hospital will ever see enough cases to study it.

That takes a different kind of study, and it exists. EUROFAST followed 306,900 children’s anesthetics across 31 European hospitals and counted every aspiration: 0.96 per 10,000 under a one-hour fluid policy, 1.83 per 10,000 under the traditional two-hour rule — statistically noninferior, with no deaths from aspiration in either group (Br J Anaesth).

Notice the shape of that. MRI shows how fast a child’s stomach empties. This trial shows what is left at one hour. EUROFAST shows the rare disaster gets no more common. And the European guideline weighs it all and rates its confidence: GRADE 1B–1C, guideline writers’ shorthand for how sure they are (Eur J Anaesthesiol).

No single study settles a question like this. A stack of different designs, each covering the others’ blind spots, is what settling looks like.

The usual honesty: one hospital, healthy children, elective non-GI surgery. None of it covers a child whose condition slows stomach emptying — those children need their own plan.

Now, about 1990

Here is the part that gets me.

In 1990, in Anesthesiology, researchers let 53 children drink clear liquids until two hours before surgery and compared them with children who fasted the old way. The drinkers’ stomachs were no fuller. And their parents rated them less irritable, with a better overall preoperative experience (Anesthesiology).

That is more or less this week’s finding, published thirty-six years ago.

A simple, humane change can take decades of confirmation before it becomes the default instruction. A family hearing “nothing after midnight” tonight isn’t getting 2026’s evidence. They may be getting 1989’s.

The researchers behind it

I looked up first author Aruna Parameswari, an anesthesiologist at Sri Ramachandra, and there is a clear thread through her work: using bedside ultrasound to answer questions anesthesia has historically had to estimate. Difficult airways, breathing-tube confirmation, children’s pain blocks, and now gastric contents.

Senior author Mahesh Vakamudi has been publishing since the mid-1990s, with much of his earlier work in cardiac anesthesia.

And there is Peter Frykholm, whose group wrote the European fasting guideline and then ran EUROFAST to check how the change played out — write the recommendation, then test it at scale.

This is one of the things I love about following researchers instead of just reading individual papers. You start to see how a field moves.

My take

“Nothing after midnight” has survived because it is easy to say, easy to print, and impossible to misunderstand. It can also mean a four-year-old who has been awake since 5 a.m. is still not allowed a sip of water at 10.

The answer is not less attention to fasting. It is better, more specific instructions: what a child can drink, how much, when to stop, and which children need a different plan. If your child has surgery coming, asking for exactly that is completely fair.

Nine more to check out if you have time

2. A warm pack cut emergence agitation from 56% to 7%

This may be the simplest intervention I read about all week.

Researchers randomized 217 surgical patients with urinary catheters to a 20-minute warm compress over the lower abdomen after surgery — or an identical room-temperature pack, a true placebo control.

Emergence agitation, the thrashing restlessness some patients have as they wake from anesthesia, fell from 56.5% to 7.3%. Shivering went from 7.4% to zero (J Anesth).

One hospital, one trial, and a result that absolutely needs replication.

But if it holds up? A warm pack may be one of the cheapest useful interventions published in anesthesia this year.

3. Pregnant patients on extracorporeal life support survived better than expected

Researchers in Taiwan looked at 247 pregnant patients who required extracorporeal life support over two decades.

These were extremely sick patients, and 42-day mortality was still 41.3%.

But compared with nonpregnant women of the same age on the same level of support, pregnant patients had lower in-hospital mortality (43.7% vs. 53.8%) and better long-term survival (Br J Anaesth).

The part worth remembering: survival was not the end of the story. Kidney, cardiovascular, and psychiatric problems remained elevated long afterward.

4. The GLP-1 question got another useful piece of evidence

What happens if someone taking a GLP-1 drug — the Ozempic class — follows a specific pre-procedure plan?

Researchers prospectively studied 256 patients undergoing endoscopy. GLP-1 users held the medication for a week and had clear liquids only for the final 24 hours; controls followed the standard fast.

Retained gastric contents were 8% vs. 6%, with no significant difference and no aspiration events (Can J Anaesth).

Small observational study, so not the final answer. But with this preparation strategy, GLP-1 users did not look dramatically different from everyone else.

5. An anesthesia handoff during surgery may not be as dangerous as we assume

A meta-analysis pooled 13 studies and more than one million patients. About 17% had a change in anesthesia clinician during the case.

There was no significant association between handoff and death or major complications, and the randomized multicenter trial included in the review found the same thing (Anesth Analg).

That does not mean handoffs do not matter. How we communicate during them obviously does.

But the handoff itself may not be the problem we assumed it was.

6. A music game reduced children’s preoperative anxiety by 38%

Researchers randomized 80 children ages 3 to 11 to usual care or an interactive tablet-based music program before surgery.

Anxiety fell 38%, with the largest effect in the youngest and most anxious children (Sci Rep).

No medication. No meaningful side effects. Something that could actually fit into a normal pre-op workflow.

I would like to see much more research like this.

7. Someone randomized 1,368 patients to different angles of a hospital bed

And I mean that as a compliment.

After thrombectomy for stroke, patients at 67 centers were assigned to lie flat or have the head of the bed elevated 30–40° for 72 hours.

At 90 days, disability was not significantly different, though the trial could not rule out a modest benefit of elevation (BMJ).

Why did I save this one? Because adjusting the head of a bed is something nurses and clinicians do constantly.

Not every important research question requires a new drug or device. Sometimes it is literally: what angle should the bed be?

8. What happens to nurses at work matters

This study included 90,196 female nurses across 67 hospitals in China and examined 14 types of occupational trauma.

Workplace violence and sexual harassment contributed most strongly to the overall exposure score, which in turn was the strongest predictor of moderate-to-severe depressive symptoms. Emergency and psychiatric nurses had the greatest burden (Int J Nurs Stud).

It is cross-sectional, so it cannot prove causation.

But nearly 100,000 nurses is a very large dataset putting numbers behind something nurses have been saying for a long time: working conditions matter.

9. AI did not beat the boring old prediction model

This might be my favorite negative study of the week.

Researchers at Boston Children’s built machine-learning models using 1,023,639 pediatric surgical encounters to predict postoperative mortality.

The AI performed extremely well.

So did the existing regression-based score.

AUC 0.956 vs. 0.958 — an accuracy measure where 1.0 is perfect. Essentially no clinical advantage (Anesth Analg).

This is what good AI research should do: actually test whether the complicated thing improves on the simple thing.

Sometimes it does not.

10. A researcher opened his conference talk in a language he does not speak — in his own voice

This one is different, but it was too interesting to leave out.

At a pediatric anesthesia conference, a team led by Clyde Matava of Toronto’s Hospital for Sick Children demonstrated real-time AI translation using consumer technology. A synthesized version of the speaker’s own voice delivered the talk’s introduction in the audience’s language, and audience questions were translated back through an earpiece (Paediatr Anaesth).

This was a demonstration, not an outcomes study. We do not know whether it improved understanding, learning, or accuracy.

But as someone who loves the international part of conferences, I immediately started thinking about what this could mean.

What happens when researchers can actually present and discuss their work across languages without needing to switch to a shared language?

There is your fever dream question for the week.

That’s Edition 1.

My hope is that every Friday you leave knowing a little more, feeling a little less intimidated by research, and maybe with a new question of your own to chase down.

The one paper you can’t miss will always stay free. Paid members get the full 10 every Friday.

And if you want to be here from the beginning, Founding Members are on the list: first to know, first invited, and along for whatever comes next.

After my post last week about midazolam (also commonly known by the brand name Versed) one of my good friends texted me:

“Is that what I’m going to get for my colonoscopy next week?”

I told her probably not. For a routine colonoscopy in a young, healthy patient, we often skip the Versed entirely and use a different medication that can do most of the work on its own: propofol.

I explained that she would likely feel completely asleep, remember little or nothing about the procedure, and wake up before it felt like much time had passed at all.

And as I was texting her this, I realized this was an important post to write.

Because colonoscopy is one of the most common places people encounter anesthesia, and for many patients it is their first experience with it. But what patients call “being put to sleep” can mean several very different things to us.

So what are we actually doing during a colonoscopy? Why is propofol used so often? And what are we watching while you are comfortably unaware of everything happening around you?

That is where this gets interesting.

What Happens When You Go Back to the Room?

Once you are in the procedure room, you will usually be asked to turn onto your left side and get comfortable. Whenever possible, we like patients to position themselves before sedation rather than moving them afterward. You know what feels comfortable for your body, and it helps us make sure you are well positioned before the procedure begins.

Then we set up the monitors: a pulse oximeter to watch your oxygen, oxygen in your nose through a nasal cannula, EKG stickers for your heart, and a blood pressure cuff that squeezes every three to five minutes. Once everything is ready, we give the propofol, make sure you are asleep, and the procedure starts.

The gastroenterologist passes a long, flexible scope with a camera through the rectum and up through the colon, examining the lining on the way back out and removing any polyp worth removing. That ability to intervene is the whole point. It usually takes well under an hour.

And while the gastroenterologist watches your colon, anesthesia sits right there watching you the entire time to make sure you are safe and comfortable.

How We Got From Versed and Fentanyl to Propofol

For years the classic recipe was midazolam (Versed) plus an opioid, usually fentanyl. Versed relaxes you and quietly keeps memories from forming; fentanyl treats the discomfort. Together they produce what was traditionally called “conscious sedation,” although moderate sedation is the better term now (you may also hear it called “twilight sedation”). You might drift in and out, respond when someone speaks to you, notice some pressure — and still wake up convinced you slept through the entire thing. That combination is still in use, and if your center uses it, you are not receiving outdated care.

Then propofol entered the picture. It was approved in the United States in 1989, and its use spread far beyond the operating room. One nationwide analysis of more than 4.6 million outpatient colonoscopies found that anesthesia-service involvement rose from roughly 16% to 58% between 2006 and 2015, closely tied to propofol-based sedation.

Propofol Is Almost Perfectly Designed for Something Short

Propofol surprises people: it provides no pain relief at all. It is a hypnotic. Its job is turning consciousness down, and it does that job fast. A clinically effective dose produces hypnosis in about 40 seconds.

The other half of the reason I love it for something short is how quickly it stops working. A 2025 Cochrane review of 33 trials and more than 12,000 patients found that propofol improves recovery time and patient satisfaction without a difference in overall complications.

“It’s Just Sedation” Is One of My Least Favorite Phrases

And for that matter, I hate the phrase “It is just…” anything.

There is a tendency to imagine sedation as anesthesia-lite: a little medicine, a nap, wake up. From your side, that is often exactly what it feels like. From mine it is different. Propofol’s therapeutic range is narrow enough that a patient can move from sleepy to deeply sedated to temporarily not breathing on small changes in dose. The FDA prescribing information warns that it can cause airway obstruction, pauses in breathing (apnea), low blood oxygen and low blood pressure, especially when given rapidly. And unlike Versed or fentanyl, propofol has no reversal drug I can give to undo it.

So it gets continuous, undivided attention. Here is what that looks like.

What I Am Actually Watching While You Sleep

The most important monitor we have to watch continuously is the capnography waveform. Pulse oximetry gets the attention, but oxygen saturation lags behind breathing and especially with supplemental oxygen it can mask poor ventilation.

Capnography watches the carbon dioxide you exhale, so it tells me your breathing has slowed or stopped before the pulse oximeter starts to drop. A meta-analysis of nine randomized trials in more than 3,000 sedated GI patients found that adding it reduced the odds of hypoxemia — a drop in blood oxygen — and a randomized colonoscopy trial found the same for desaturation during propofol sedation.

And Your Blood Pressure, Just as Closely

Propofol also tends to lower blood pressure especially after a bowel prep and fasting. A 2022 analysis pooled 939 patients sedated with propofol for colonoscopy and found that 36% had at least one episode meeting the study’s definition of hypotension. Larger doses and longer sedation meant deeper, longer dips.

Deep Sedation Is Not a Fixed Place

We talk about levels of sedation — minimal, moderate, deep, general anesthesia — as though they are totally separate concepts. But that is really not accurate. It is a continuum. Under moderate sedation you respond purposefully to voice or light touch, and your breathing takes care of itself. Under deep sedation you are not easily aroused, and your breathing or airway may need help. Under general anesthesia you are unarousable even to painful stimulation.

A patient intended for one level can drift into the next. That is why I am careful when I tell someone, “you won’t need a breathing tube.” For a routine colonoscopy with propofol, one usually is not part of the plan — but I never promise your airway will need zero help. Sometimes the entire anesthetic is preserving your own breathing while gently holding the airway open.

That is the skill. And it is why sedation is real medicine: whoever provides it has to be able to monitor you, recognize when you have gone deeper than intended, and rescue your airway and circulation when necessary.

Do You Dream Under Anesthesia?

Maybe. Dreaming around propofol is real, and it has become a fascinating corner of anesthesia research. In a classic study of 200 patients sedated for colonoscopy, 19% reported dreaming when questioned immediately after waking. A 2026 British Journal of Anaesthesia scoping review of 157 studies and more than 87,000 people found propofol among the drugs most consistently associated with dream recall — and most of those dreams tend to be pleasant and ordinary.

So: Do They Put You to Sleep for a Colonoscopy?

Very often, yes — and at many centers that means deep sedation with propofol. The gastroenterologist examines your colon and removes anything that needs to come out. And at the head of the bed, someone is watching everything you will never remember: the first snore, the blood pressure drifting down, the CO₂ waveform flattening, the jaw lift you never knew you received.

The medication starts it. The anesthetic is everything we are doing while you sleep.

If someone you love turned 45 recently and has spent the last year saying they are definitely going to schedule that colonoscopy soon, this might be the post to send them. Screening is recommended beginning at age 45 for average-risk adults. If fear of being awake, or of being “put under,” is what is keeping someone from scheduling it, understanding what actually happens may make that part less intimidating.

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So I usually give some version of the same speech (and the colleagues I work with frequently know it by heart as well). I tell them that I am going to give them some relaxing medication through their IV while we are still in the preoperative area. It is called Versed, or midazolam.

Versed is the brand name and midazolam is the generic name, the way Motrin is ibuprofen

I say it as being similar to Ativan, Valium, or a nice glass of wine. Then I explain that I am going to push their stretcher down the hallway, hand them a party hat so they match everyone else in the operating room, and bring them into a room that will be very cold.

But not the worry, we warmed up the operating room bed for them! Once we arrive, they will slide over, I will put on all of my monitors and give them some oxygen to breathe, and then the medication that actually makes them unconscious will go through the IV. I will be there the entire time, making sure they are safe and comfortable, and that when the surgery is over, I will wake them up and bring them to the recovery room. And I will make sure they are comfortable before I leave to take care of my next patient.

Extremely frequently, if the patient has had a similar surgery before, they will stop me somewhere in the middle of this explanation.

“No, no. Last time they put me to sleep out here. I wasn’t awake when I went into the operating room.”

And then I have to explain one of the strangest things we routinely do in anesthesia. The last time they had surgery, they were likely talking to us, answering questions, following commands and maybe even moving themselves from the stretcher onto the operating room table. They just do not remember doing any of it.

The reason is Versed.

When I first learned about midazolam in anesthesia school, I found the entire concept relatively freaky. You mean to tell me that I can give someone a medication that prevents them from forming new memories but does not necessarily make them unconscious? They can still be interacting with me normally while their brain is no longer reliably saving what is happening?

Apparently, yes.

And over time, what initially seemed slightly terrifying became one of the things I find most interesting about anesthesia. Midazolam eventually became one of my very favorite medications, not only because of how useful it is clinically, but because its effects tell us something fascinating about the difference between being awake, being asleep and remembering either one. I became interested in it enough that my very first research study looked at differences in outcomes between patients who received midazolam before surgery and patients who did not.

So this is, essentially, a love letter to Versed: why we use it, what it is actually doing in the brain, why you can be awake for a period of time you will never remember, and what I found when I looked at the differences in outcomes between patients who received it and those who didn’t!

What Is Versed Doing in Your Brain?

Midazolam is a fast-acting, short-acting benzodiazepine. It works by enhancing GABA, the brain’s main inhibitory neurotransmitter, which calms neural activity and creates a smooth transition into unconsciousness.

One of my favorite things I ever learned about Versed is that the name supposedly came about because its reversal drug, flumazenil, was going to be called Reversed. The company didn’t end up calling it Reversed, but Versed still stuck. I have never been able to verify the story anywhere, so it is probably a myth but I keep telling it because it is important to not let the truth get in the way of a good story.

How it works has been verified, though. It is a remarkably reliable eraser, and we choose it partly for that. The hippocampus, the small structure that turns a passing moment into a storable memory, quiets first and most, so the dose that stops you forming new memories is lower than the dose that puts you to sleep. (The longer version is in the July post.)

The technical term is anterograde amnesia. Nothing you already know is erased. The medication stops new moments from being stored from the time it takes effect, which is why so many people remember the pre-op nurse and the IV, and then nothing at all. Amnesia is one of the three states we manage at once, as I laid out in What Is Anesthesia, Actually?, and Versed is how it often starts, before you ever see the operating room.

Why Is Midazolam So Good at Its Job?

It doesn’t burn. Its older cousin Valium doesn’t dissolve in water, so it had to be given in a solvent that stung. Midazolam was the first water-soluble benzodiazepine, so it goes in like saline, unlike another one of my favorite medications, propofol (which often feels spicy).

It has a ceiling. Benzodiazepines don’t switch the GABA receptor on by themselves; they simply increase the effects of the GABA your brain is already releasing. That built-in ceiling is a large part of why they are so safe. However, when you combine it with opioids it can still slow breathing, which is one reason someone is watching your oxygen the entire time.

It lowers the chance of remembering surgery itself. In a 2023 review of 34 randomized trials, patients who received a benzodiazepine around their anesthetic were less likely to have any awareness during surgery, the thing patients ask me about most.

And it may do a job nobody asked it to do. Which is where my study comes in.

My very first study

At the outpatient cancer surgery center where I worked, almost everyone arrives anxious (it’s cancer surgery), so about three out of four patients get midazolam. That made it the right place to test two questions anesthesia providers argue about: does the relaxing medication delay your discharge after short procedures, and does it quietly reduce nausea and vomiting afterward, the complication so many patients tell us is worse than the pain?

My colleagues and I looked at 4,057 patients over fifteen months. After adjusting for the factors that could influence the outcome ( including age, nausea risk, type of surgery, type of anesthesia, length of the case), patients who received midazolam needed rescue nausea medication less often afterward: about three fewer patients out of every hundred. And even more interesting, the time in the recovery room for patients who received midazolam were actually shorter! (The full paper is free to read.)

Since our retrospective study, a 2024 review of more than a hundred randomized trials confirmed our results and found that a benzodiazepine around surgery lowers the odds of nausea and vomiting and prevents about one in sixteen patients from getting postoperative nausea and vomiting.

Who Gets It, and Who Doesn’t?

In older adults, we use less of it, and sometimes none. Older brains are more sensitive to sedatives, and for years the teaching was to avoid benzodiazepines in older patients over worries about confusion after surgery. The newest evidence is more reassuring than the teaching: a 2024 study of more than 5,000 patients over 65 found no link between midazolam during surgery and delirium afterward, and a review of 34 randomized trials found the same.

The Hour That’s Missing

When a patient wakes up in recovery and looks genuinely surprised when I tell them the surgery is already over, it is still one of my favorite moments.

“You mean it’s done?”

Yep.

Frequently, they do not remember meeting half the people who took care of them. They do not remember the party hat. They do not remember entering the cold operating room or moving themselves onto the operating room table.

A very small dose can take someone who is terrified and help them feel calm enough to roll into an operating room. It can make an otherwise strange experience under spinal anesthesia feel like a nap. It may even offer benefits we were not originally giving it for, including a small reduction in postoperative nausea.

And perhaps strangest of all, it can create an hour in your life when you were awake enough to talk, laugh, answer questions and follow directions, but your brain was no longer reliably saving the experience.

So if you have spent years convinced that someone put you to sleep in the preoperative area before your last surgery, you may be right.

But there is also a pretty good chance you had simply met my favorite drug.

One more thing, before next Thursday: on August 27, Art of Anesthesia opens a paid tier! Every explainer (this post and every post like it) will stay free. Founding memberships will be open through September 10. The whole story is in next Thursday’s post!

At least once a week, I have a conversation with my mother-in-law about natural supplements and the ways that Ayurvedic medications can be far more effective than Western medications. My most recent success story was using arnica ointment on my sore hand (after writing too much…) and being surprised by both how quickly it felt better and how much the literature supported its use for these types of orthopedic injuries.

Often she’ll say something like, “These medications are very effective!” assuming that any hesitation I have is because I don’t think they’ll work as well as more traditional medications.

And that’s actually the issue: I completely agree with how effective they can be.

Eastern medicine practices have been used effectively for thousands of years, whereas I’ve seen drastic changes in how we practice Western medicine just in the 15 years I’ve been practicing anesthesia. My bigger concern is that because these medications are effective, they can also have other effects on the body and interact with other medications in ways I want to understand. A lot of that comes from my anesthesia background and thinking about how everything a patient takes can affect what we do for surgery.

One of the first things that happens anytime you see a medical professional is that you’re asked to list your current medications. We often call this “medication reconciliation,” and it can look wildly different depending on the patient. Some people have color-coded charts with every medication documented down to the minute. Others show up with a bag of unlabeled pills.

One of the places this matters most is on the day of surgery. Almost everyone you interact with before anesthesia will confirm your medication list and ask when you last took each medication.

I think there can be some confusion about why this matters so much—and why you’re asked the same questions over and over. The simple answer is that these medications can directly affect your anesthesia and surgery, and anything that important is going to be checked by multiple people.

But rather than just saying, “It’s really important,” I thought it would be more helpful to break down the why behind some of the medications and supplements we ask about most often, including why we may want you to take some and hold others.

Can I take my blood pressure medication before surgery?

Let’s start with one of the most important and common medications: the answer for blood pressure medications is “it depends on which one.”

Beta blockers (metoprolol, atenolol, carvedilol): if you take one every day, current guidelines recommend continuing it right through surgery (2024 AHA/ACC perioperative guideline). This is taken seriously enough that in a study of more than 400,000 anesthetics, patients whose chronic beta blocker was withdrawn around surgery had over three times the odds of dying within the first 48 hours (Kertai et al., Anesthesia & Analgesia 2018) — and for years, hospitals were formally graded on beta-blocker continuation as a national quality measure.

The flip side: that does not mean starting one fresh before surgery, which guidance specifically warns against (2024 AHA/ACC). A drug your body has lived with for years is not the same drug meeting your body for the first time on surgery morning.

The -prils and -sartans (lisinopril, enalapril, losartan, valsartan): these are the ones your team may ask you to hold. Blood pressure commonly falls when anesthesia begins, and these medications can deepen that dip and blunt the drugs I use to treat it. Even this isn’t settled, though. The STOP-or-NOT trial randomized 2,222 patients to continue or stop before major surgery: complications were identical either way, but low blood pressure during surgery occurred in 54% of the continue group versus 41% (JAMA, 2024) — and for someone taking the same drug for heart failure rather than hypertension, continuing may be the right call (2024 AHA/ACC). Different teams land in different places, which is exactly why your instruction has to come from yours.

What about Motrin, Advil, aspirin, and Tylenol?

Especially if you are having an orthopedic surgery for pain, this can be very relevant!

• Ibuprofen (Motrin, Advil) and other NSAIDs make platelets temporarily less sticky — but more briefly than most people think: after a full week of ibuprofen, platelet function normalized within about 24 hours of the last dose (Goldenberg et al., Annals of Internal Medicine 2005). For many operations an NSAID is a non-event — we use them ourselves for surgical pain. For operations where bleeding carries real consequences, your team may want a specific gap (often up to a week).

• Aspirin is different — its platelet effect is far more durable, and many people take it to protect something specific: a coronary stent, a cardiac history (2024 AHA/ACC). This is one to make sure to confirm with your surgical team and cardiologist.

• Tylenol (acetaminophen — paracetamol to most of the world) doesn’t affect platelets the way NSAIDs do, and we often give it ourselves around surgery.

Can I take cold or allergy medicine before surgery?

Your daily allergy pill is rarely the issue. Decongestants like pseudoephedrine raise heart rate and blood pressure, so they’re worth mentioning — but your anesthesia provider is going to care much more about why you’re taking cold medicine. A new cough, wheezing, or fever can change an airway plan or even cancel a surgery. If you get sick before surgery, call the surgical office rather than deciding yourself whether it’s “bad enough” and make sure to mention it to everyone prior to going to sleep.

What about anxiety medication?

If you take something daily — an SSRI, a long-standing anxiety medication — expect to continue it. In general your body will adapt to these medications and we don’t like to make sudden changes.

And if the real question is “can you give me something because I’m really nervous” — yes. Preoperative anxiety is something we assess and treat, with monitors on and a plan. What I’d rather you not do is improvise with something from home that morning (especially if it is something that you don’t usually take).

The medications that need a plan days ahead

A few categories can’t be solved with “take it” or “skip it” on surgery morning, because the real decision happens earlier:

• Blood thinners. The same drug preventing a stroke makes surgical bleeding harder to control. Continue, hold, or bridge is a risk calculation among your surgeon, your prescriber, and sometimes your cardiologist — individualized by design (2024 AHA/ACC). If you take one, make sure every office involved in your surgery knows.

• Diabetes medications. A fasting morning changes what the usual dose would do. Insulin is usually adjusted, not simply taken or skipped. We usually try to have patients with diabetes first thing in the morning to reduce the impact of fasting.

• SGLT2 inhibitors (Jardiance, Farxiga, Invokana). These can contribute to an unusual form of ketoacidosis around surgery — sometimes without dramatically elevated blood sugar — and current guidance recommends stopping them three to four days before a scheduled operation (2024 AHA/ACC). But again, always check!

• GLP-1 medications (Ozempic, Wegovy, Mounjaro, Zepbound). They slow stomach emptying, which collides with the fasting rules. The newest multi-society guidance is individualized: most patients continue, and higher-risk patients get extra precautions like a liquid diet the day before or a gastric ultrasound day-of (multisociety guidance, 2024). But these guidelines are changing almost daily and by provider and institution. For now: your team needs to know you’re on one.

And then there are the supplements

Supplements are often more consequential than the prescribed medications and often less reported.

• Garlic — concentrated supplements can affect platelets and are usually stopped before elective surgery (SPAQI; Ang-Lee et al., JAMA 2001). Garlic the food is fine: volunteers who ate 4.2 grams of raw garlic in Greek tzatziki — daily, for a week — showed no platelet impairment (Scharbert et al., Anesthesia & Analgesia 2007).

• Fish oil — the reputation says bleeding; the evidence says otherwise. In a randomized trial of 1,516 cardiac surgery patients, fish oil did not increase major bleeding, and the fish-oil group needed fewer transfusions (Akintoye et al., 2018). Consensus recommendations support continuing it (SPAQI).

• Ginkgo — a long reputation, underwhelming data: added to daily aspirin in a randomized trial of older adults, it produced no significant change in platelet function or bruising (Gardner et al., 2007). Still usually held before surgery, because the benefit of continuing it through an operation is low (SPAQI).

• Melatonin — has actually been studied as a preoperative medication: across 27 randomized trials, it reduced preoperative anxiety about as well as midazolam (Madsen et al., Cochrane 2020).

• Kava and valerian — work on the same brain pathways as the anesthesia medications (Ang-Lee, JAMA 2001); usually stopped, partly because formulations vary and rigorous surgical studies are thin (SPAQI).

  

Three common questions about medications before surgery

If I’m fasting, how do I take my pills? If your surgical team has instructed you to take a medication on the morning of surgery, it is generally taken with a small sip of water. Your fasting instructions should specify which medications to take and which to hold.

What if I already took something I wasn’t supposed to? Tell your team what you took, how much, and when. Do not skip surgery or conceal it because you are worried you will get in trouble. The information lets the anesthesia and surgical teams determine whether anything actually needs to change.

Do vitamins and supplements really count? Yes. They may ultimately have no effect whatsoever on your anesthetic, but that is a determination your anesthesia team can make. Put the vitamins, herbal products, powders, gummies, sleep supplements, fish oil, and everything else on the list along with your prescriptions.

If surgery is coming up for you or someone you love — especially someone with a pill organizer on the kitchen counter — send them this post.

If you found this through a search: I write one of these every Thursday — subscribing is free.

Whenever this comes up in casual conversation, I find that people are often surprised.

Anesthesia is made up of several different components, and one of the most fundamental is analgesia: preventing and treating pain. That may seem unnecessary if someone is unconscious and will not remember the procedure. But a lack of awareness does not mean the body is unaffected. Even when the mind does not consciously register pain, the nervous system still responds to it.

I have been thinking about this a lot lately because several friends have told me about painful procedures they underwent while fully awake, with little or no meaningful pain relief.

It made me question why, if we recognize that pain has physiologic consequences even under anesthesia, so many awake patients, particularly women, are still expected to undergo painful procedures with little or no pain management.

Being Unconscious and Being Pain-Free Are Not the Same Thing

Pain is a conscious experience. It is what happens when the brain receives information from the body and experiences it as hurting.

Nociception is different. It is the nervous system detecting and responding to something potentially damaging, such as an incision, heat from cautery, pressure, stretching, or movement of tissue. Nociception can affect heart rate, blood pressure, movement, stress hormones, and other physiologic responses without becoming a conscious experience of pain.

Different types of anesthesia address the problem in different ways.

With a spinal anesthetic, local anesthetic temporarily interrupts transmission through the nerves and spinal cord. Signals from the surgical area are blocked before they can be experienced as pain. The same block also prevents signals from the brain from reaching the legs, which is why you cannot move them until the spinal begins to wear off.

General anesthesia does not create the same kind of physical barrier between the surgical site and the nervous system. Instead, anesthetic and analgesic medications alter how signals are transmitted and processed throughout the nervous system while preventing awareness and the conscious experience of the operation.

The incision can still begin a signal. Your body may still react. But the signal does not become an experience you inhabit or a memory you carry with you.

This is why unconsciousness and analgesia are separate parts of anesthesia, something I wrote about early on in What Is Anesthesia, Actually?. A medication can make someone unconscious without adequately controlling the body’s response to surgery. A different medication can provide excellent pain relief without making someone unconscious at all.

During an operation, we are managing all of it at once: awareness, nociception, movement, memory, breathing, circulation, and what will happen when you wake up.

The Job Is to Stay Ahead of the Surgery

Another part of anesthesia that I was surprised to learn, was that the amount of medication we give depends on the intensity of the stimulus.

Before the incision, when you are sleeping on the operating table, there may be very little stimulation. Giving a large amount of pain medication at that point could lower your blood pressure, slow your heart rate, suppress your breathing, or make it harder for you to wake up comfortably later.

The first incision is stimulating. Probably one of the most stimulating parts of surgery. So are cautery, traction on tissue, inflation of the abdomen during laparoscopic surgery, manipulation of organs, and the drilling and pounding involved in orthopedic surgery. Vibration is one of the most stimulating things that can happen.

So the anesthetic changes with it.

Modern pain management is usually multimodal, which means using several approaches that work in different places rather than asking one medication to do everything. Depending on the procedure and the patient, that might include an opioid, acetaminophen, an anti-inflammatory medication, local anesthetic injected by the surgeon, or a nerve block that interrupts the signal closer to its source.

Using several approaches often allows us to use less of any single medication, especially opioids. That matters because opioids are effective, but they can also cause nausea, sedation, itching, constipation, and slowed breathing.

The goal is to give enough, at the right moment, for this patient. Too little can leave the body mounting a strong response to surgery and make the transition into recovery more painful. Too much can cause low blood pressure, delayed breathing, nausea, or prolonged sedation.

What I do promise is that safety and comfort will guide every decision. In that order, but never as though comfort does not matter.

Why Treat a Response You Cannot Feel?

A reasonable question is: if you are unconscious and will have no memory of the operation, why not simply keep you asleep and ignore everything else?

Because unconsciousness does not turn off the rest of the body.

Surgical injury can activate the sympathetic nervous system, hormonal pathways, inflammation, and metabolic changes. Heart rate and blood pressure may rise. The body releases stress hormones and alters how it uses sugar, fat, and protein. The size of that response depends on the operation, the anesthetic, and the person undergoing it. We treat nociception because we want to avoid unnecessary physiologic strain, use medication thoughtfully, and make the transition from surgery to recovery as smooth as possible.

“Just Take Some Motrin Beforehand”

My friend was scheduled for an office procedure and was told to take Motrin beforehand.

She immediately knew it was going to be bad.

Nobody tells you to take pain medication before something they genuinely expect to be painless. The instruction itself was the warning. What unsettled her was that they clearly anticipated pain, but Motrin was still the entire plan.

She was right. The procedure was extremely painful, and the Motrin did not come close to touching it.

What We Ask Awake Patients to Tolerate

An office is not an operating room, and it cannot simply be turned into one.

Sedation requires appropriate staffing, monitoring, equipment, emergency preparation, and somewhere for the patient to recover. It may require fasting and a ride home. It introduces its own risks and often adds costs that are not covered by insurance.

The clinicians performing these procedures are usually not indifferent to pain. Many are working within short appointments and systems that were not designed to provide individualized procedural analgesia.

But there is a great deal of room between doing nothing and giving someone general anesthesia.

IUD insertion is one of the clearest examples.

Pain varies considerably between patients, and many people tolerate placement well. Others experience severe pain. In one study, patients rated their maximum pain during insertion at an average of approximately 65 on a 100-point scale. The clinicians performing the procedures estimated the patients’ pain at approximately 35. Their agreement about which part of the procedure hurt most was barely better than chance. A separate study, in a different country and a different health system, found the same gap.

The problem is not that every person receiving an IUD needs sedation or a cervical block.The problem is that we have not always been honest about how much it might hurt or consistent about offering the available options.

The guidance has begun to change. In 2024, the CDC recommended that patients receive individualized counseling about pain and pain-management options before IUD placement and noted that topical lidocaine or an injected paracervical block may help. In 2025, the American College of Obstetricians and Gynecologists went further, recommending that clinicians offer local anesthetic options for IUD insertion, including topical agents and paracervical blocks.

And then there is the Motrin.

Anti-inflammatory medications can help with cramping after IUD placement. But when they are used alone, the evidence does not show that they reliably reduce the pain of the insertion itself.

My friend did not fail to take the right medication. The medication had been asked to do a job it was unlikely to do.

What Pain Can Leave Behind

Pain matters in the moment. Sometimes it matters long after the procedure is over.

Severe pain during the first postoperative day is one of the factors associated with persistent pain months later. In a study of more than 3,000 surgical patients, every 10% increase in the amount of the first postoperative day spent in severe pain was associated with a 30% increase in the incidence of persistent pain one year later.

That does not mean every episode of severe pain causes chronic pain. The operation, preexisting pain, the nervous system, genetics, emotional state, and many other factors contribute. It does mean that acute pain is not always a brief inconvenience that disappears without consequence.

One of the findings I find most striking comes from obstetrics. Researchers followed nearly 1,300 women after childbirth. Those who experienced severe acute pain had two and a half times the risk of persistent pain and three times the risk of screening positive for postpartum depression eight weeks later. The severity of the pain predicted those outcomes. The type of delivery did not.

In a randomized trial involving almost 700 colonoscopy patients, researchers made the final portion of the procedure less uncomfortable for one group. The procedure lasted longer, but because it ended more gently, those patients remembered the entire experience more favorably and were more likely to return for another colonoscopy during the following five years.The mechanism may run through memory, fear, trust, and the way the experience ended rather than through the pain alone.

That raises the stakes on the parts clinicians can control: what someone was told beforehand, whether realistic options were offered, whether they were believed when they said it hurt, and what happened next.

A procedure may last fifteen minutes.

The memory of it does not.

The takeaway

If you are having surgery under general anesthesia, you should not consciously experience the operation.

Your body may still respond to surgical stimulation, and someone will be watching for and treating that response throughout the case. We are not waiting for you to wake up and tell us that something hurt. Staying ahead of it is a large part of what we are doing during the hours you will never remember.

If you are staying awake for a procedure, ask about pain before the day it happens, while there is still time to make a plan.

Ask what people usually feel.

Ask what medication or local anesthetic is available.

Ask what will happen if the first plan is not enough.

Ask whether the procedure can be paused if you need it to stop.

And if it hurts while it is happening, say so. If nothing changes, say it again.

You are not being dramatic. You are not making the procedure harder. You are providing clinically important information about something no monitor can measure for you.

Were you offered anything for the pain? What were you told to expect beforehand? Tell me in the comments.

The interesting part is that the blanket “nothing after midnight” rule is fairly outdated.

For most healthy adults having an elective procedure, current guidelines generally allow clear liquids until about two hours before anesthesia. A light meal usually requires at least six hours, while fried or fatty foods, meat, and heavier meals may require eight hours or longer.

These recommendations are not limited to general anesthesia. They can also apply to procedures involving deep sedation or regional anesthesia because sedation can weaken airway reflexes, and an anesthetic plan occasionally needs to change once a procedure has begun.

It doesn’t really make sense that “black coffee” is considered a “clear liquid”, but once you add cream it no longer is. Because these distinctions are complicated—and because operating-room schedules can change—many surgical instructions still default to midnight. It is simple, memorable, and conservative. It also creates a buffer in case a procedure is moved earlier in the day. But simplicity for the system can mean a very long fast for the patient.

Patients often assume this must be necessary to make the stomach completely empty, or that food would somehow interfere with the operation itself.

But your stomach is not really the organ we are trying to protect.

Your lungs are.

Where Food and Air Nearly Cross Paths

Food, liquid, and air all pass through the back of your throat before traveling down separate pathways. Air moves through the larynx and trachea toward the lungs, while food and liquid pass behind the airway into the esophagus and stomach.

When you are awake, your body is remarkably good at keeping those pathways separate. You swallow automatically, the structures around the larynx close as food passes, and if something approaches the airway, you cough, gag, clear your throat, or swallow again. You probably do not appreciate how much coordination is involved until you accidentally inhale a sip of water and spend the next minute coughing.

Anesthesia temporarily interferes with many of those protections.

As you become unconscious, the medications used for anesthesia reduce muscle tone and suppress the reflexes that normally protect your airway. Deep sedation can have a similar effect, even when you are not completely unconscious. If stomach contents move upward into the throat during that period, you may not cough, swallow, or close your airway in response. Instead, that material can pass through the vocal cords and enter the lungs.

This is called pulmonary aspiration.

The risk is especially relevant during induction, as the patient becomes unconscious and the anesthesia team establishes the airway, and again during emergence, as airway devices are removed and normal reflexes return. An endotracheal tube helps protect the airway once it is correctly positioned and the cuff is inflated, but there is still a period before the tube is placed—and another after it is removed—when the body’s usual defenses are reduced.

Aspiration can also happen during procedures performed under sedation, when there may be no breathing tube in place at all.

Why Aspiration Matters

The lungs are designed to exchange oxygen and carbon dioxide. They are not designed to handle stomach acid, partially digested food, or gastrointestinal secretions.

Acidic fluid can produce a severe inflammatory injury known as aspiration pneumonitis. Solid particles can obstruct smaller airways, and bacteria carried into the lungs can contribute to aspiration pneumonia (a bacterial infection). In severe cases, aspiration can lead to respiratory failure, prolonged mechanical ventilation, or death.

Fortunately, aspiration during elective anesthesia is rare. Estimates vary depending on the population and type of surgery, but it generally occurs only a few times per 10,000 anesthetics. Still, it is one of those complications anesthesia providers take seriously because the consequences can be substantial when it does occur.

Much of anesthesia involves anticipating low-probability events before they happen and quietly putting layers of protection in place. Fasting is one of those layers. The patient’s position, medication choices, airway technique, suction equipment, and the timing of induction are others.

The goal is not to rely on any one precaution. It is to make aspiration as unlikely as possible and to be prepared if it occurs.

How Midnight Became the Rule

Much of our modern concern about aspiration can be traced to a landmark paper published in 1946 by obstetrician Curtis Mendelson. He described aspiration among pregnant patients receiving general anesthesia and helped establish that acidic stomach contents could cause a serious chemical injury to the lungs, now commonly known as Mendelson syndrome.

This was enormously important work, but the anesthesia practiced in 1946 looked very different from the anesthesia we practice today. Many patients received ether. Modern airway devices, medications, monitoring standards, and aspiration-prevention techniques did not exist. General anesthesia was also used far more commonly during childbirth than it is now.

As awareness of aspiration grew, fasting practices became increasingly conservative. Eventually, “nothing after midnight” became the default because it was easy to explain and easy to standardize.

The science continued to evolve. The default instruction often did not.

We now know that clear liquids generally leave the stomach much faster than solid food and that allowing appropriate clear liquids closer to surgery can reduce thirst, hunger, headaches, and dehydration without meaningfully increasing risk in appropriately selected patients. Some institutions have moved toward even more liberal clear-liquid policies, although the exact approach varies.

The Standard Rules Do Not Apply Equally to Everyone

The familiar two, six, and eight-hour intervals are intended primarily for otherwise healthy patients undergoing elective procedures. Some patients have conditions that slow gastric emptying or make regurgitation more likely, which means their instructions may need to be different.

Emergency surgery is an obvious example. If someone needs an operation immediately, waiting six or eight hours may be more dangerous than proceeding. In that situation, the anesthesia team assumes the patient may have a full stomach and changes the airway plan accordingly.

Other factors can complicate the picture, including bowel obstruction, gastroparesis (a condition that slows stomach movement), significant nausea or vomiting, certain esophageal disorders, pregnancy, previous stomach surgery, and some neurologic or metabolic conditions.

GLP-1 medications such as semaglutide and tirzepatide have brought much more attention to this issue because they can slow gastric emptying. Early recommendations were quite conservative, but the guidance has become more individualized. Most patients can continue these medications before elective surgery, while those at higher risk—such as patients who recently increased their dose, are experiencing significant gastrointestinal symptoms, or have another condition that slows gastric emptying—may need a liquid-only diet before the procedure, an adjusted anesthesia plan, or additional evaluation.

In some settings, a trained anesthesia provider may use gastric ultrasound to look at the stomach immediately before surgery. It cannot answer every question, and it is not available everywhere, but it can sometimes help distinguish a stomach that appears empty from one containing a significant amount of fluid or solid material.

What if You Accidentally Eat or Drink?

Tell your anesthesia provider exactly what you had, how much you had, and when you had it.

Do not hide it because you are embarrassed or worried that your procedure will be canceled. A sip of water is not the same as a latte, and a piece of toast is not the same as a steak dinner. Those details matter.

Depending on what you consumed, your medical history, and how urgent the procedure is, the team may decide it is safe to proceed, wait longer, use gastric ultrasound, modify the anesthetic technique, or postpone the procedure.

That decision is not a punishment for failing to follow instructions. It is a risk calculation based on what may still be in your stomach, how likely it is to move upward, and what could happen if it enters your lungs while your body’s normal defenses are temporarily suppressed.

This is also why vague instructions are such a problem. Patients should not be expected to guess whether coffee counts, whether they can take their morning medications, or whether “nothing after midnight” includes water. Good fasting instructions should clearly explain what patients may consume, when they need to stop, and whom they should contact if they are uncertain.

The next time someone tells you not to eat before surgery, remember that the goal is not to create a perfectly empty stomach or to keep food out of the surgeon’s way. We ask you to fast because anesthesia temporarily weakens the reflexes that normally keep the contents of your digestive tract out of your airway.

Modern fasting recommendations are trying to balance two goals: reducing the risk of aspiration while avoiding unnecessary thirst, hunger, dehydration, and discomfort. That balance will not be identical for every patient, which is why the safest instructions are still the ones given by the team that knows your medical history and your procedure.

The stomach is where the risk begins, but the lungs are what we are protecting.

If this gave you a different understanding of why fasting matters before surgery, share it with someone having an upcoming procedure. And if you’re taking a GLP-1 medication, make absolutely sure your anesthesia team knows—it changes how we prepare.

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There are parts we do understand, in extraordinary detail. We can identify the receptors anesthetic drugs bind to, measure how they change individual neurons, watch the electrical rhythms of the brain reorganize, and track the breakdown and return of communication between entire brain networks.

But if you are part of the team that finally explains how all of those changes become the disappearance of conscious experience, there is a good chance you are going to win a Nobel Prize for it.

To be fair to anesthesia, science can’t explain how the consciousness you’re having right now arises either. Anesthesia didn’t create that mystery—it just gives us a switch.

It Isn’t One Thing

Part of the confusion is that we say someone is “under,” as if anesthesia were a single state made by a single drug.

It isn’t. General anesthesia handles several separate things at once: you shouldn’t be consciously aware of the operation, shouldn’t feel pain, shouldn’t form memories of it, and shouldn’t move. Those effects aren’t interchangeable. A sedative can relax you without making you unconscious. An opioid treats pain without reliably making you unconscious. A paralytic stops movement while providing no unconsciousness and no amnesia at all.

Stillness is not anesthesia. Each effect is its own dial. And the memory dial is where things get really strange.

You Were Awake. You Just Don’t Remember It

Before almost every surgery, I have a conversation the patient won’t remember having. I ask about their teeth, their last meal, I might joke about their socks. They answer. Then they wake up in recovery and tell the nurse, with total sincerity, that they never even made it to the operating room.

But they did. They talked to me the whole way there.

Most people assume the forgetting is just a side effect of being unconscious. It isn’t—because for a lot of what you don’t remember, you weren’t unconscious. You were awake, following instructions, moving yourself onto the table. You just weren’t recording any of it.

The dose that stops you forming new memories is lower than the dose that puts you to sleep. So there’s a window where you’re awake by every outward sign—you’re talking, moving, responding—while the recorder is already off.

The drug behind that is often midazolam (brand name Versed), a relative of Valium we give before heading to the OR. It softens the anxiety, and it’s a remarkably reliable eraser—we choose it partly for that. It works by boosting GABA, the brain’s main “slow down” signal, which quiets neurons everywhere. But the hippocampus—the small structure that turns a passing moment into a storable memory—quiets first and most.

It’s like the recording studio goes dark while the rest of the building is still lit. The experience streams in; nobody hits record.

So when a patient says “I closed my eyes and then I was in recovery,” it isn’t that the brain lived eight hours as an instant. It’s that no continuous memory was made in between. The last memory before surgery sits right beside the first one after.

It Doesn’t Turn the Brain Off — It Reorganizes It

The transition from awake to unconscious usually comes from propofol, the milky-white medication that works faster than anyone expects. One moment they’re looking at me; the next, they’re not responding.

And here’s the surprise: the brain doesn’t go quiet. On an EEG, activity becomes slower and more synchronized, locked into big repetitive waves. The awake brain constantly moves among many different patterns—taking in information, comparing it with memory, updating its picture of the world. Under anesthesia, that range collapses. Activity becomes repetitive, local, and unable to travel across the brain.

The clue is in what still works. An unconscious brain often registers the first flicker of a sound— the hearing center responds—but the signal doesn’t spread through the rest of the network. The sound reaches the brain. What fails is the step that turns it into “someone is speaking to me”.

I picture it less like the lights going out and more like the phone lines between the rooms going down: rooms still lit, still busy, no longer talking to each other.

How Different Drugs Do the Same Thing (In Different Ways)

Here’s what researchers discovered: Three completely different anesthetic drugs, each working through different mechanisms, all did the same thing to brain cells.

Brain cells have parts that receive feedback from other parts of the brain. Think of it like a cell’s antenna—it’s how the cell stays connected to everything else. What the researchers found was that these three different drugs all blocked that antenna. The cell stayed active, but it couldn’t receive signals from the rest of the brain anymore. The feedback line went quiet.

Different drugs. Same result: disconnection.

Not every anesthetic even slows the brain down. Ketamine can actually increase activity in some regions, and the brain can look busy while the patient is completely disconnected from the world. That’s one of the biggest clues we have: unconsciousness can’t just mean “less brain activity.” Sometimes there’s more.

What fails is the brain’s ability to organize activity into a single, coherent experience—to have all the different pieces talking to each other. Different receptors, different patterns, same endpoint: a brain that can’t hold the conversation together.

But no single receptor, structure, or rhythm has been shown to explain every anesthetic in every person. That’s the part we’re still solving.

So Do We Understand Anesthesia?

Yes, and not completely. We understand the drugs extraordinarily well: how fast they act, how they clear, how illness and age change the dose, how to support your breathing and blood pressure the entire time.

What we don’t have is one clean line from a molecule to the disappearance of the self.

And here’s the reassuring part: safety doesn’t depend on solving consciousness. Anesthesia isn’t a drug you’re given and left to work on its own. It’s a changing state that’s tended the whole way through. The surgery gets more stimulating, and the anesthetic changes. Your pressure shifts, and it changes again. The person at the head of the bed is part of the system.

I can tell you exactly what propofol does to your receptors and still find the moment remarkable: you’re talking to me, and then you’re not, and hours later you come back with no memory of the time between.

My job isn’t to solve the mystery of the mind. It’s to know what the anesthetic is doing to you, respond to every change, and stay at the head of the bed until you’re safely back.

If this gives you a different understanding of what happens when you go under, share it with someone who’s having surgery soon. Knowing that anesthesia is a carefully tended state—not just a drug and hope—makes the whole thing feel less mysterious and more secure.

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For an average healthy person undergoing a routine surgery, it usually goes something like:

“Anytime you undergo anesthesia, there is potential for injury to your organs, including your brain, heart, and lungs. Since you are young and healthy, the most likely complication for you is a sore throat or nausea and vomiting.”

But when I talk to patients, friends, or family members after surgery, I have learned that they don’t often expect a sore throat. So when it happens, it can be really upsetting and distracting.

So here is the full explanation of why your throat may be sore after surgery.

What Was in My Throat?

If you’ve read my posts on intubation and securing the airway, you already know the two devices we reach for. Here is the part those posts didn’t cover: what each one does to your throat.

An endotracheal tube passes between the vocal cords and sits in the trachea. It is the most secure airway for many operations—and because it rests against the most sensitive tissue in your throat, it is also the one most likely to leave you sore.

A supraglottic airway (you may hear it called an LMA) sits above the vocal cords instead of passing through them. Nothing crosses the cords, so it tends to cause less lingering discomfort.

Which one we use comes down to safety, not comfort—your aspiration risk, anatomy, lung function, surgical position, and how long you’ll be under. When both are safe, we choose the gentler one.

The Simple Answer

Most postoperative sore throats come down to temporary irritation and inflammation—basically, a little “road rash” on delicate tissue.

Your vocal cords and the tissues around them are delicate and densely supplied with nerves. Their entire job is to detect anything entering the airway that is not supposed to be there. During intubation, those tissues may come into contact with the laryngoscope, the breathing tube, the stylet, the suction catheter, or other instruments.

Even when placement is smooth and uncomplicated, the airway device stays in contact with those tissues for the entire operation.

Two factors do a lot of the work:

Pressure (Especially Cuff Pressure)

Endotracheal tubes use a small inflatable cuff to seal the airway. It needs enough pressure to do its job, but too much pressure irritates tissue.

Randomized trials show that when cuff pressure is measured and actively controlled, instead of estimated by feel, postoperative sore throat can drop substantially. It’s one of the most concrete, controllable things we can do.

Contact and Friction

Even a perfectly placed device sits in contact with airway tissues for the length of the operation. Movement—repositioning, surgical positioning, coughing as you wake up—can add friction to tissue that’s already a bit irritated.

Dryness can make it all feel worse, especially after fasting and medications that cut down saliva. But the evidence points to pressure, contact, and inflammation as bigger culprits than dry gases alone.

How Common Is This?

Actually, it is fairly common. Researchers even have a name for it: postoperative sore throat, or POST. Patients describe it as scratchiness, burning, dryness, pain with swallowing, hoarseness, or the feeling that a cold is coming on.

The numbers vary because researchers ask at different times and define it differently. A 2026 systematic review of 162 studies and more than 21,000 patients found symptoms in about 32% of endotracheal-tube patients one hour after surgery, falling to 16% by 24 hours.

For supraglottic airways, the rate fell from roughly 29% to 10% over the same window. An earlier prospective study of 809 adults put the figure at 40% after intubation.

So irritation can happen with either device. It is simply more likely to linger when a tube has passed through the vocal cords.

Why Do Some People Feel It More?

Two people can have similar surgeries and wake up feeling completely different.

Your risk goes up if you had an endotracheal tube rather than a supraglottic airway, or if it was a larger tube with higher cuff pressure. Difficult placement, multiple intubation attempts, and longer anesthesia time all increase irritation. Coughing during emergence adds friction to already-sensitive tissue.

The type of surgery matters too. Head, neck, thyroid, oral, or cervical spine surgery—or any case where additional tubes or instruments pass through your mouth or throat—puts you at higher risk.

Women report postoperative sore throat more often in many studies. This likely has to do with anatomy: a standard-sized tube occupies proportionally more space in a smaller larynx, creating more contact and pressure.

Can It Be Prevented?

Not entirely. But it’s not inevitable either. Some of the proven ways to reduce the incidence include:

• Choose the smallest tube that safely does the job

• Position the patient carefully and aim for successful placement on the first attempt

• Measure and control cuff pressure

• Secure the airway to limit unnecessary movement

• Reassess the tube after major position changes

Researchers have also studied corticosteroids, anti-inflammatory medications, local anesthetics, ketamine, magnesium, medicated lozenges, and other topical treatments. Some help in specific situations, but there’s no single preventive treatment that works for everyone.

How Long Does It Last?

The pattern is reassuringly predictable.

Symptoms generally begin within hours of waking, are most noticeable early, and improve substantially by the next day. Most resolve within one to three days. In one large study of over 800 adults, the average was about 16 hours. A small minority still noticed symptoms four days later.

What Helps Once You’re Awake?

Most research focuses on prevention, but simple supportive steps are reasonable:

• Sip fluids once you’re cleared to drink (warm tea, broth, ice chips—whatever feels best)

• Lozenges can help; a gentle warm saltwater gargle is fine if swallowing is comfortable

• Rest a hoarse voice; try not to keep clearing your throat

• Acetaminophen can help; anti-inflammatories may help if your surgical team says they’re safe for you

When Should You Actually Worry?

A typical postoperative sore throat is mild to moderate, worse with swallowing or talking, and clearly improving within 24 to 72 hours. You should still be able to breathe normally, drink, and swallow.

Seek urgent medical attention for:

• Difficulty breathing

• Noisy or high-pitched breathing

• Rapidly increasing swelling of the throat or neck

• Inability to swallow liquids or manage saliva

• Drooling or the sensation that your airway is closing

Contact your surgical or anesthesia team for:

• Severe or worsening throat pain

• Increasing difficulty swallowing

• Fever with worsening throat or chest symptoms

• Coughing up more than a small streak of blood

• A crackling sensation beneath the skin of the neck

• A markedly weak, breathy, or absent voice

• Hoarseness that is not clearly improving after several days

A mildly raspy voice immediately after surgery is common. A profoundly changed voice, worsening symptoms, or trouble breathing or swallowing is different. Serious airway injuries are rare. But persistent symptoms deserve an evaluation rather than an automatic, “that is just the anesthesia.”

Tell Your Next Anesthesia Team

If nothing else, I hope you remember this part:

If you had a sore throat after a surgery, make sure to tell your anesthesia provider before your next operation—even a dental one.

Two reasons.

First, we can often do something about it. Knowing a previous tube left you raw for days lets us plan around it next time—the airway device, the tube size, how carefully we watch cuff pressure. Your history tilts the odds in your favor.

Second, and this is the one that matters more: sometimes a sore throat is a clue that your airway was hard to manage—that it took extra attempts, or a different technique, to place the tube safely. That is the single most important thing your next anesthesia team can know in advance. We assess every airway before you go to sleep, but the most difficult airway is the unexpected one. “They had a hard time,” “I was told my airway was tricky,” “it took a while”—any of it changes how we prepare, sometimes before you’re ever unconscious.

A routine sore throat by itself usually doesn’t mean you were difficult to intubate. But you’re the one person who carries that history from one operating room to the next. Handing it to us is one of the most useful things a patient can do.

If this gave you a different understanding of what happens after anesthesia, share it with someone who’s having surgery soon. Knowing what to expect—and what’s normal—makes recovery less scary.

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When I was writing it, I realized that many people don’t actually know how many people are in the OR—or what all of their jobs are.

A typical room may have six, eight, or sometimes more than a dozen people in it. Each has been trained for a different part of the operation, and each is watching you from a different angle.

Here is what that actually looks like.

Why Are There So Many People?

Surgery used to happen in amphitheater-style rooms, with physicians and students sitting in rows above the table to watch. It was medicine, but it was also a demonstration.

On October 16, 1846, in a domed amphitheater now known as the Ether Dome at Massachusetts General Hospital, dentist William Morton administered ether while surgeon John Collins Warren removed a tumor from a patient’s neck. The gallery watched.

Once patients no longer had to be awake for surgery, everything changed. Operations could go deeper, last longer, and become more complex. Sterile technique, continuous monitoring, imaging, specialized instruments, and safer anesthesia transformed the room even more.

Some hospitals still have viewing areas or teaching rooms built into or around operating spaces. And television medicine loves them (especially Grey’s Anatomy). But in real life, I have personally never seen one used. I would actually love to hear from other medical colleagues if you have!

The modern OR still has a lot of people in it, but not as an audience. Each person is there because they are responsible for a different part of the case.

Anesthesia became its own profession. Operating room nursing became its own specialty. Surgical technologists, first assistants, perfusionists, imaging technologists, sterile processing teams, environmental services, and others took on parts of surgery that require their own training.

There are a lot of people because surgery is no longer just the operation. It is anesthesia, sterility, positioning, monitoring, instruments, imaging, documentation, specimens, implants, medications, turnover, recovery, and a hundred small checks that have to happen in the right order.

And one of the biggest things that organizes the whole room is the sterile field.

Sterile vs. Not Sterile

Before introducing the people in the room, it helps to understand one basic OR rule: not everyone is sterile.

Sterile means an item has gone through a validated process to destroy microorganisms, including bacterial spores, so it can be safely used in surgery. That process starts long before the patient enters the room. Instruments are cleaned, inspected, assembled into trays, packaged, sterilized, tracked, and sent back to the OR.

Once the patient is in the operating room, the sterile field is created around the surgical site. It includes the prepped skin, the surgical drapes, and the tops of the instrument tables. The surgeon, first assistant, and scrub person are usually the people working inside that field. They have scrubbed their hands, put on sterile gowns and gloves, and can touch sterile instruments.

Anesthesia is usually not sterile. There are exceptions, like when we place a central line, spinal, or epidural. But even then, we are not “scrubbed in” to the case. We are performing a single sterile procedure, then we return to our main job: taking care of the patient, not participating in the surgery itself.

The scrub person and circulating nurse are constantly protecting the sterile field. They are watching the instruments, the packaging, the drapes, the hands, and the movement around the table. All of it.

When in doubt, throw it out. That is the OR rule. If something touches a non-sterile surface, or if there is any question about whether it stayed sterile, it comes out of use. One of the most important rules we tell anyone coming into the OR for the first time — stay far away from anything blue (the color of the sterile drapes)!

At the Surgical Field: The Surgeon

The surgeon is the person most patients already know about.

They planned the operation, explained what needed to be done, and perform the surgical part of the case. They are focused on the anatomy, the disease, the repair, the removal, the reconstruction, or whatever brought you to the OR.

Across the Table: The First Assistant

Across from or beside the surgeon is often a first assistant. This may be a physician assistant, surgical resident, fellow, RN first assistant, certified surgical first assistant, or another qualified surgical assistant, depending on the case and the hospital.

The first assistant does much more than hold a retractor (although that in itself can be a very hard job). They also help expose the surgical area, suction blood or fluid out of the way, control bleeding, handle tissue, place or cut sutures, assist with closure, and keep the operation moving safely.

A typical first assistant is always anticipating, watching where the surgeon is working, what is blocking the view, and what will be needed next. During a long case, the rhythm between the surgeon and first assistant is often wordless.

A surgical PA has completed a master’s-level PA program, passed national boards, and may have additional surgical or specialty training. A resident or fellow is a physician in surgical training. An RN first assistant is a registered nurse with perioperative experience and additional first-assist training. A certified surgical first assistant usually comes through a surgical technology or surgical assisting pathway and has completed additional education and certification.

I have spent most of my career working closely with many PAs in particular. After enough years and enough cases together, you learn one another’s patterns. They know the jokes I tell my patients and the things I am paranoid about. I know how long it usually takes them to close and who I can ask about specific parts of a procedure.

At the Instrument Table: The Scrub Person

The scrub person is usually a surgical technologist or sometimes a registered nurse. They organize the sterile instruments and supplies, pass instruments, manage sutures, handle specimens, and help protect the sterile field.

Watching an experienced scrub person work can look like choreography. They usually know which instrument the surgeon will need before it is requested and will have it ready to grab without the surgeon needing to look.

Most scrub persons are surgical technologists who completed a surgical technology program and passed a national exam to become certified. Their training includes anatomy, microbiology, sterile technique, instrumentation, and the flow of many different procedures.

The person at the instrument table has to know the names of the instruments, what they are used for, and when the surgeon is likely to need them. Some trays have dozens of pieces. Some have more. The scrub person has to know what is there, what is missing, what has been used, and what needs to stay sterile.

They also share responsibility for the count. Sponges, sharps, and instruments are counted at specific points during the case by the scrub person and circulating nurse together. If the count does not match, the entire room stops and the discrepancy has to be resolved.

The Person Who Sees the Whole Room: The Circulating Nurse

Someone has to be free to move. That’s the circulator.

The circulating nurse is a registered nurse who works outside the sterile field. While the surgical team is focused on the operation and I am focused on your physiology, the circulator is watching the whole room.

The patient. The positioning. The documentation. The equipment. The implants. The specimens. The supplies. The timing. The count.

They confirm your identity, procedure, allergies, consent, positioning, equipment, medications, and supplies. They document what happens. They open sterile items without contaminating them. They manage specimens. They count with the scrub person. The circulator is constantly scanning.

The training starts with nursing school and RN licensure, but OR nursing is its own specialty. New circulating nurses usually need months of perioperative training after they are hired, and then years of experience to get really good. Many go on to earn CNOR certification, which requires at least two years and 2,400 hours of perioperative nursing practice.

And Then, Depending on the Case

Other specialists join when needed.

A perfusionist may run the heart-lung machine during cardiac surgery.

A neuromonitoring specialist may track signals through the brain, spinal cord, and nerves during certain neurologic, spine, or vascular procedures.

A radiologic technologist may operate imaging equipment during orthopedic, spine, vascular, or interventional cases.

During cancer surgery, the operation may pause while a pathologist examines tissue and reports findings back to the surgeon.

There may also be residents, fellows, PA students, nursing students, medical students, or student nurse anesthetists. That is how every one of us learned, with responsibility matched to training and supervision.

And then there are the people patients almost never see: the sterile processing team sterilizing instruments, the environmental services team cleaning and turning over the room, the aides and transporters helping move and position patients safely, the pharmacy staff preparing medications, the lab and blood bank staff ready if the case needs them, the PACU nurses waiting on the other side.

A single operation depends on far more people than can fit around the table.

You Are Not Alone

You won’t meet most of these people. You won’t see the coordination, the rhythm, the way everyone knows exactly what to do without being told.

But they’re all there. Focused on you.

Add up the years of training standing around one operating table, and it is usually measured in decades. Everyone in that room has a different job. But everyone in that room has the same goal: to take care of you.

I am focused on you. And everyone else is focused on you too — just from a different angle.

For those of you who work in an OR: Who controls the music in your room, and which specialty has the most predictable playlist? Reply and tell me.

If this gave you a different understanding of what happens in an operating room, share it with someone who’s having surgery. Knowing who’s there and that they’re all focused on keeping you safe makes the whole thing feel less scary.

The Art of Anesthesia explains what actually happens before, during, and after anesthesia — and the parts patients rarely get to see.

Subscribe for weekly posts breaking down what actually happens during anesthesia and in the OR. New posts every Thursday. It’s free.

Having surgery is scary for a lot of reasons. You are thinking about what might happen during the operation, but also about what comes after: how much pain you will be in, how long recovery will take, when you will feel like yourself again.

These are conversations I have all the time with friends and family, and many of those concerns are completely justified. Recovery is often harder, slower, and more painful than people expect. I have seen patients, friends, and family members caught off guard by how long it takes to feel normal again, or by how much discomfort can continue after they leave the hospital.

But there is one fear that comes up more than almost any other. Sometimes people ask it seriously. Sometimes they make a joke about it. And sometimes it has been made much worse by horror-movie versions of anesthesia:

“What if I wake up during surgery?”

It is a reasonable fear, and it deserves a clear answer.

What Does “Awareness” Even Mean?

There’s a medical term for this: accidental awareness during general anesthesia (AAGA). In simple terms, it’s when you remember something that happened during surgery when you were supposed to be completely asleep.

Not every anesthetic is aiming for the same thing. During monitored anesthesia care (MAC) or sedation, it is often expected that you drift in and out, hear voices, respond briefly, or remember fragments. You might even be expected to follow commands! That does not necessarily mean anything went wrong.

Most AAGA-focused research and audits use a recall-based definition: you later remember something that happened during the anesthetic period when you were intended to have no awareness.

That’s why clinicians and researchers work hard to separate AAGA from common look-alikes:

• Induction memories (right before you’re fully anesthetized)

• Emergence memories (as anesthetic levels fall near the end)

• Dreaming (common; usually unrelated to true intraoperative events)

These experiences have different causes, different prevention strategies, and (often) different long-term impact.

The Actual Numbers

The largest study ever done on accidental awareness was the Fifth National Audit Project, better known as NAP5. Across the United Kingdom and Ireland, researchers tracked awareness across nearly 2.8 million surgeries during a year.

They found approximately one case of certain, probable, or possible awareness for every 19,600 general anesthetics.

That is reassuring. But it’s also not the whole story, because awareness isn’t evenly distributed. It’s more common in certain situations:

• Emergency surgery (1 in 670 for Cesarean delivery)

• Cardiac, thoracic, or obstetric surgery

• Surgery done outside regular working hours

• Cases using IV anesthesia with paralytics

• If you’ve had awareness before (which makes it roughly 5 times more likely to happen again)

Accidental awareness is not distributed evenly across all anesthetics. It is concentrated in cases where the anesthesia plan, the patient’s condition, or the urgency of the operation makes delivering and continuously maintaining anesthesia more complicated, especially when medications are also preventing the patient from moving.

And within that already rare group, the experience patients fear most—being fully conscious, in pain, aware of a prolonged operation, and unable to communicate—is rarer still.

The Paralysis Piece (And Why It Matters)

For certain surgeries, we use medication called paralytics that temporarily stop your muscles from moving. This makes placing a breathing tube safer and keeps you still when even a small movement could be dangerous.

But they don’t make you unconscious, don’t relieve pain, and don’t erase memory. So if consciousness came back while a paralytic was still working, you couldn’t move or signal to tell us.

Which is why:

• Awareness is more common in cases that use paralytics (about 1 in 8,200, compared with 1 in 136,000 without it)

• We monitor paralyzed patients more closely

• We confirm your strength has fully returned before the breathing tube comes out

A reassuring note: A lot of the old “awake and paralyzed” stories come from a surprisingly preventable problem: before medications were standardized and labeled the way they are now, a patient was occasionally given a paralytic instead of a pain medication by mistake—awake, but unable to move or say so. Color-coded labels, routine cross-checks, and continuous monitoring have made that almost unheard of today. When awareness with paralysis does happen now, it’s almost always during a true emergency, when keeping you alive has to come first.

How Do We Actually Know You’re Still Under?

We don’t rely on one thing. We build layers of evidence:

The anesthetic itself. With inhaled anesthesia, we continuously measure how much anesthetic you are breathing in and out—proof it’s actually reaching your brain.

The delivery system. If you are getting IV anesthesia, I’m watching the IV site, the tubing, the pump, the rate, the connections.

How your body responds. Heart rate, blood pressure, breathing, whether you are sweating or tearing up—all of it gives me information.

Brain activity monitoring (when needed). For the most complex cases—especially IV anesthesia with no gas to measure, or paralysis with no movement to watch—we can add a monitor that tracks brain activity. It’s useful, but it’s not perfect. Temperature, age, blood flow, even muscle movement can affect it. And the evidence shows the limit honestly: in the biggest trials, it didn’t perform better than simply tracking the anesthetic gas and watching the patient carefully.

What You Should Tell Us Before Surgery

The single most important thing: tell us if you have ever had any experience that might have been awareness—even if you’re not sure what it was. What do you remember? Voices? Pressure or pain? Were you unable to move? When did it happen—at the start, during, or while waking up?

Previous awareness changes our entire plan.

The same goes for heavy use of alcohol, opioid, benzodiazepine, or cannabis. Any medications you take daily. Any previous trouble with anesthesia.

We need this information. It changes how we dose you and what we watch.

If you think it happened to you: Tell your anesthesiology team.

What I Want Everyone To Know

This fear is understandable. Being unable to move, unable to signal, and unsure what’s happening is one of the most vulnerable scenarios a person can imagine.

But two things can be true at once:

• True accidental awareness is rare. The most extreme “fully awake through the surgery” version is rarer still.

• When risk is higher (emergencies, certain high-risk surgeries, TIVA + paralysis), we already know those scenarios and add layers of prevention: delivery monitoring, alarms, system checks, and sometimes brain activity monitoring.

But most importantly, you are never alone during surgery.

I tell every single patient that I will be there the entire time, making sure they are safe and comfortable. There are a lot of people in the operating room, and everyone has a different job. While the surgeon is focused on the operation, I am focused on you. From the moment you come into the operating room until you are awake again in the recovery room, my job is to watch over you, keep you safe, and never leave your side.

If this gave you a different understanding, share it with someone who’s having surgery.

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The Art of Anesthesia explains what actually happens before, during, and after anesthesia — and the parts patients rarely get to see.

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For the next several hours, my job is to notice what you cannot.

That means much more than watching numbers on a screen. I am watching the way air moves into your lungs, whether blood is reaching the organs that need it, how your body is responding to the surgery, whether your medications are reaching you, and whether anything in the room has changed since the last time I looked.

And then I look again.

This is the first in a series about what happens while you are under anesthesia—not only the machines and measurements, but the actual work of keeping you safe, unconscious, and physiologically stable while surgery is happening. We will explore why some people remember parts of an anesthetic, why your throat may hurt afterward, what happens as you begin to wake up, and how your body recovers.

But before any of that, it helps to understand the most important rule in anesthesia care:

Rule Number One: We Never Leave

The first modern anesthesia-monitoring standards did not begin with a machine. They began with a requirement that a qualified anesthesia professional remain in the room for the entire anesthetic.

That sounds so obvious now that it is difficult to imagine it ever needed to be stated. But as recently as the early 1980s, there was no national standard defining exactly how patients should be monitored during surgery. Some hospitals had begun using pulse oximeters and carbon dioxide monitors. Others had not. The equipment available and the expectations for monitoring could vary considerably from one hospital to another.

That began to change at Harvard-affiliated hospitals in 1985 and then nationally in 1986, when the American Society of Anesthesiologists adopted its Standards for Basic Anesthetic Monitoring. Those standards established principles that still shape anesthesia care today:

• Qualified anesthesia personnel must remain continuously present.

• The patient’s oxygenation, ventilation, and circulation must be continually evaluated, with temperature monitored when clinically significant changes are expected or suspected.

It was an early effort to formally define what safe, minute-to-minute care during anesthesia should include. And importantly, it placed the person before the technology. Before specifying what the machines should measure, the standards required someone qualified to remain at the patient’s side, continuously watching, evaluating, and responding.

The technology has changed enormously since then. Our monitors are faster, more sensitive, and capable of displaying thousands of data points during a single operation. But the underlying work remains surprisingly similar.

For every minute that you are asleep, I am there, repeatedly looking around the room and asking the same essential questions.

The Left-To-Right Sweep

Continuous monitoring does not mean staring at a screen.

Most anesthesia professionals develop a repeated visual scan of the entire room. Some call it a left-to-right sweep, a circle, or simply the scan. The sequence changes depending on how the operating room is arranged, but the purpose is always the same: to make sure that every part of the system is still working as it should.

I often begin at the IV pole. Is the fluid still dripping? Are the medication infusions running at the correct rates? Is the tubing connected, unclamped, and free of kinks? A pump may say that a medication is infusing, but I still need to confirm that it is actually moving through the tubing and reaching the patient.

Then I look at the patient: the position of the head and body, the airway, the breathing circuit, and whatever parts of the patient remain visible beneath the drapes. I check that the head and neck have not shifted, that the breathing tube and circuit remain secure, and that nothing is pressing against the face or eyes. In a crowded operating room, pressure can come from an instrument, a piece of equipment, a heavy drape, or even an arm resting where it should not be.

Then I look at the operation itself. Where are we in the procedure? What is happening now, and what is likely to happen next? Is there more bleeding than there was a few minutes ago? What is collecting in the suction canister? Does the reported blood loss match what I can see in the surgical field, on the sponges, and in the suction tubing?

Only then do I return to the monitors and the anesthesia machine: oxygen saturation, the carbon dioxide waveform from each exhaled breath, heart rhythm, blood pressure, temperature, anesthetic concentration, airway pressures, breath volumes, and ventilator settings.

And then I begin again.

The sweep continues for the entire operation. It is how we notice an IV that has stopped flowing, pressure developing on a patient’s face, blood loss gradually increasing, or a subtle change in how hard the ventilator must work to move air into the lungs.

The Monitor Doesn’t Keep You Safe — The Person Does

There are few moments in healthcare when one patient is watched as closely as during anesthesia. Your breathing is measured breath by breath, your heart beat by beat, while your blood pressure, oxygen level, medications, position, and response to surgery are followed continuously.

That is part of what drew me to anesthesia: the chance to care for one patient at a time, with my full attention.

But that attention is not focused on any single monitor or number. Throughout the operation, I am repeatedly asking:

Are the fluids and medications actually reaching you?

Are you getting enough oxygen—and are you moving air effectively?

Is blood reaching the organs that need it?

Are you unconscious and adequately anesthetized for what is happening?

Is your position still safe?

Are your muscles relaxed when they need to be—and recovering when the operation is ending?

Are you staying warm?

What is the surgery doing to your body right now, and what is likely to happen next?

None of these questions can be answered by looking at a single number. The monitors provide the information. The anesthesia professional connects it to the patient, the operation, and everything else happening in the room.

Over the next several weeks, we will take these questions one at a time and look at how we answer them.

If this gave you a different understanding of what happens during surgery, share it with someone who has an operation coming up.

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The Art of Anesthesia explains what happens before, during, and after anesthesia — and the parts of the work patients rarely get to see.

Subscribe for weekly posts breaking down what actually happens during anesthesia and in the OR. New posts every Thursday. It’s free.

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By the time you are wheeled into the operating room, a significant part of the safety work has already happened. The breathing system has been tested, the oxygen supply has been confirmed, suction is working, monitors and alarms are ready, and the plan for getting oxygen into your lungs has already been thought through. You may remember the hallway, the lights, the warm blanket, or a few moments of conversation before you drift off, but you probably will not see the preparation that happened before any of that, when the room was still empty, and your anesthesia team was making sure the machine and the room were ready for you.

That machine check is not just a technical routine. It is one of the ways anesthesia builds in a margin of safety before the anesthetic even begins. Here is what that pre-flight checklist actually involves, and why each step exists.

Preparing the Space

One of the interesting parts of anesthesia that I took for granted until I started teaching CRNA students is that we do not simply walk into an operating room and accept the space exactly as it is. We shape it around the patient, the procedure, and the plan. We move the anesthesia machine into position, adjust the bed, bring some equipment closer, move other things out of the way, make sure the suction is within reach, confirm that the monitors are visible, organize the airway equipment, and arrange the medications in a sequence that makes sense for the case.

That preparation may look like small logistical work, but it is part of the safety system. A well-prepared room gives the anesthesia provider immediate access to what is needed, especially in the moments when seconds matter. A poorly arranged room can make even routine tasks harder, and in an emergency, the difference between “right there” and “somewhere behind me” can become very important.

From the outside, the anesthesia machine may look like a cart with screens, tubing, numbers, and alarms. During surgery, though, it can become one of the most important systems in the room. It delivers oxygen, helps carry anesthetic vapor to keep you unconscious, moves breaths in and out of your lungs when needed, removes carbon dioxide from the breathing circuit, and alerts us if something is not working the way it should.

So, preparing the space is not housekeeping. It is part of the pre-flight checklist. Before the anesthetic begins, we are not just checking that the machine turns on; we are making sure the room is organized, the equipment is reachable, the backup plan is realistic, and the system we are about to rely on has been deliberately set up for the patient in front of us.

Oxygen: Built So One Failure Is Not Enough

The first question in any anesthesia machine check is the most basic one: where is the oxygen coming from, and what happens if that source fails?

Most operating rooms have oxygen piped in through the wall, but anesthesia is not designed around a single point of failure. There is also a backup oxygen cylinder attached to the machine, and part of the check is confirming that it is present, sufficiently full, and ready to use before the day’s cases begin.

One of the details I find most interesting is that the system is physically designed to make some errors impossible. You cannot simply connect the wrong gas to an anesthesia machine and hope no one notices. Medical gas cylinders use a pin pattern called the Pin Index Safety System, where the holes only line up with the correct gas. Wall connectors are also gas-specific, so an oxygen hose will not properly connect to a nitrous oxide outlet. Color coding adds another layer, but the real safety feature is mechanical. The system assumes that people work quickly, under pressure, and in complex environments, so it is built to prevent a dangerous connection before it can happen.

The oxygen sensor is also checked. In room air, it should read about 21%, because that is the oxygen concentration of the air we are all breathing right now. When pure oxygen is turned on, that number should rise. That simple check matters because it confirms that the sensor is telling the truth at a value we already know, so we can trust it later when the number is clinically important.

This is the logic of anesthesia safety. A machine self-test is helpful, but it does not replace the parts of the setup that still need to be verified by the person using the machine. The question is not only, “Is oxygen available?” The better question is, “If this source fails, what happens next?” The goal is to make sure the patient is never one failure away from danger.

The Breathing Circuit and the Breath That Has to Work

The breathing circuit is the loop of tubing that carries gas from the anesthesia machine to your lungs and back again. Before you are asleep, the provider pressurizes that system by hand and checks whether it holds pressure. They are looking for the slow sag of a leak, the faint hiss of a loose connection, or the bag that does not fill or empty the way it should, because a problem in this circuit can mean the machine cannot reliably move air into the patient.

This is tested carefully because once anesthesia begins, the margin for delay becomes much smaller. Before you go under, you are often asked to breathe oxygen through a mask for a few minutes. That is not a formality. It replaces nitrogen in the lungs with oxygen and creates a reserve in the air sacs, buying extra time after you stop breathing on your own. A working breathing circuit is how that oxygen reserve is protected and used. A leaking or disconnected circuit can waste that reserve at exactly the moment it is needed most.

This is the scenario the machine check is meant to prevent: you are asleep, paralyzed, and no longer breathing independently; the provider seals the mask, squeezes the breathing bag, and the expected movement does not happen. At that point, the clock has already started. The time to discover a leak or a disconnected tube is before anyone is asleep, not after.

This is not just theoretical. Reviews of anesthesia malpractice claims have found that equipment problems account for only a small fraction of cases, but when they do occur, the consequences are often severe. Disconnects and misconnects in the breathing circuit are among the most common equipment-related problems, and many of these events have been judged preventable with better setup and monitoring.

The equipment rarely fails in a dramatic, isolated way. More often, the danger is that something small was missed, moved, loosened, or assumed to be fine. In anesthesia, something being connected a few minutes ago is not the same as proving it is connected now.

Unconsciousness Is a Dose You Can Measure

The gas that helps keep you unconscious during surgery begins as a liquid anesthetic inside a vaporizer. The vaporizer turns that liquid into a precise vapor that can be mixed with the gases you breathe. During the machine check, the provider confirms that the correct anesthetic is present, that there is enough of it, that the vaporizer is seated and locked into place, and that the dial is off when it should be off.

One of the surprising things about anesthesia is that “how asleep” someone is can be discussed in terms of concentration. Inhaled anesthetics are measured and compared using a standard concept called minimum alveolar concentration, or MAC, which refers to the concentration of anesthetic in the lungs at which half of the patients would not move in response to a surgical incision. It is not a perfect measure of every patient’s anesthetic depth, but it gives anesthesia providers a useful reference point for dosing and adjusting inhaled anesthetics.

Changing the dial changes the concentration of anesthetic vapor in the gas being delivered to the patient, and that affects the depth of anesthesia. Too little anesthetic can lead to movement, physiologic stress, or, rarely, awareness. Too much can contribute to low blood pressure, delayed emergence, and other complications. The point is not simply to make someone unconscious; it is to give the right amount for the patient, the procedure, and the moment.

The Canister Under the Machine

Under the anesthesia machine is one of the least futuristic-looking parts of the setup: a clear canister filled with pale granules. It looks simple, but it is doing important chemistry throughout the case.

Those granules are carbon dioxide absorbent, often soda lime. Every breath you exhale contains carbon dioxide, and in a closed-circuit breathing system, that carbon dioxide needs to be removed so it is not rebreathed. The absorbent neutralizes carbon dioxide as gas passes through it, and a color change helps show when the absorbent is becoming exhausted. It is quiet, old-fashioned chemistry happening underneath the screens and alarms.

There is also a reason this canister gets checked carefully. If the carbon dioxide absorbent becomes excessively dry, it can react with some inhaled anesthetics and produce dangerous byproducts, including carbon monoxide. In rare circumstances, the reaction can generate heat. Published reports have described fires, and at least one explosion, within anesthesia breathing systems; there have also been cases where patients accumulated carbon monoxide without any obvious early warning except for changes detected on monitors. The specific absorbent most strongly associated with these reactions was removed from the market, and newer formulations were developed to reduce this risk.

So the canister is not just a container of granules. It is part of the breathing system, part of the chemistry of the anesthetic, and part of the safety check. Anesthesia safety is built around respecting what is possible, not only what is likely.

Everything Else That Gets Checked

The machine check also includes several other parts of the setup, each with its own safety logic.

Suction has to be on, connected, strong enough to clear an airway, and within reach. If a patient vomits, bleeds, or has secretions that need to be cleared quickly, that is not the moment to discover that suction is not working or is across the room.

The airway equipment has to be ready before the first medication is given. That means the breathing tube, backup sizes, laryngoscope, video laryngoscope, oral airway, and backup airway devices are selected and organized before the patient is asleep. You do not want to anesthetize someone and then begin looking for the backup plan, because the window for preparation closes very quickly once a patient stops breathing on their own.

The medications are also prepared in advance: induction medications, pain medications, paralytics, reversal agents, and rescue medications for changes in blood pressure or heart rate. They are drawn up, labeled, and arranged so they can be used quickly and correctly. Many anesthesia medications are clear liquids in syringes that look almost identical, so labeling every syringe every time is one of the simplest and highest-yield safety practices we have.

The Invisible Work That Saves Lives

None of this is improvised. Anesthesia has built much of its safety culture deliberately, and earlier than many other areas of medicine. In 1985, clinicians founded the Anesthesia Patient Safety Foundation around the idea that no patient should be harmed by anesthesia care. It was the first organization of its kind in any medical specialty, and the language of “patient safety,” now used throughout healthcare, is closely tied to that movement.

That safety work helped push the specialty toward better machine design, more reliable monitoring, stronger checklists, and simulation-based training for emergencies that providers hope never to encounter. It is part of why anesthesia, which was once one of the riskier parts of surgery, is now often described as one of medicine’s major safety success stories.

The interesting thing about this work is that it matters most on the days when nothing goes wrong, which is almost every day. In one large study, anesthetics in which equipment was checked against a protocol and the check was documented were associated with substantially lower odds of death or coma within 24 hours. In other words, the checklist was not just paperwork. It showed up in the outcomes.

You (as a patient) will probably never feel the difference that a check-up makes. The loose connection that was tightened, the leak that was caught, the dried-out absorbent that was replaced, the suction that was fixed before you arrived—all of those become non-events. They become the surgery you barely remember.

That is the point of the pre-flight checklist. The best version of this work is invisible. The safest day is often the one where, from the patient’s perspective, nothing unusual happened at all.

Next week

Once the machine is checked and you’re under, what is the provider actually watching? I’ll walk through the monitors—what each one sees, and the one thing none of them can do on their own.

If someone you love has surgery coming up, send them this. Knowing what happens in that room before they arrive is the kind of thing that makes the whole day less frightening.

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And if you’ve been under yourself, what did you wonder about in those last few seconds before you counted backward? Reply and tell me.

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Even when people do notice it, they usually think of it as “the machine that puts you to sleep.”

It’s not. The machine does not perform anesthesia by itself. The anesthesia team does that. The machine just gives us a controlled way to deliver oxygen, add anesthetics, support your breathing, remove carbon dioxide, and monitor what you are breathing in and out.

It is part ventilator, part gas delivery system, part monitor, and part safety system. And one of the first things anesthesia providers learn is not just how to use it, but how it works — the chemistry, physics, mechanics, alarms, pressure limits, vaporizer safeguards, breathing circuit checks, and backup systems built into it.

We are also expected to troubleshoot it when something goes wrong, often in the middle of surgery, while you are asleep, and everyone else is focused on the operation.

Every day, we check the machine before it is used. Before every case, we check it again. Next week, I’ll get into those checks and the safety systems behind them. But first, I want to explain what this machine is actually doing while a patient is under anesthesia.

The Basic Loop: How It Works

At the highest level, the anesthesia machine is built around a loop.

Oxygen and other medical gases enter the machine under pressure. The machine reduces and controls that pressure, allows us to set exact flow rates, and can add inhaled anesthetic vapor. That gas mixture then travels through the breathing circuit to the patient’s lungs.

When the patient exhales, the gas comes back through the circuit. We measure what is coming back, remove carbon dioxide, and continue the cycle.

That is the basic loop: gas in, gas out, measured continuously.

During general anesthesia, a patient may not be breathing normally. They may not be protecting their airway. They are also not awake to respond to low oxygen, rising carbon dioxide, airway obstruction, or changes in ventilation the way they normally would.

The anesthesia machine helps us support those functions while giving us continuous information about what is happening. It does not replace clinical judgment. It gives us the data, the controls, and the safety systems we need to manage a patient while they are anesthetized.

One of the most useful parts of the machine is that we are not just delivering anesthetic gas and hoping it is working. We can measure what the patient is inhaling and what they are exhaling. The exhaled anesthetic concentration gives us important information about how much anesthetic is actually reaching the patient.

Oxygen Comes First

The most important job of the anesthesia machine is to deliver oxygen.

Oxygen moves through the anesthesia machine, into the breathing circuit, and then to the patient through a mask, breathing tube, or other airway device. From there, it reaches the lungs, crosses into the blood, and is delivered to the brain, heart, and the rest of the body.

In everyday life, you breathe room air, which is about 21% oxygen. During anesthesia, we can adjust the oxygen concentration depending on what the patient needs. Around major transitions — like going to sleep or waking up — we often deliver a higher percentage of oxygen to build up a reserve. We may also use more oxygen if a patient’s underlying disease, positioning, or the surgery itself makes oxygenation more difficult.

But higher oxygen is not always better. In some cases, especially when surgery involves the airway or other fire-risk situations, we may intentionally lower the oxygen concentration to reduce the risk of operating room fire. So oxygen delivery is not simply “more is better.” It is something we adjust throughout the case based on the patient, the procedure, and what is happening in real time.

Once oxygen is moving through the machine, the next question is what else can be added to that gas mixture. For many general anesthetics, that is where the vaporizer comes in.

How Anesthetic Vapor Gets Into Your Body

When people talk about “anesthesia gas,” it can sound like there is simply a tank of anesthetic gas connected to the machine. That is not usually how it works.

Some anesthetics, like nitrous oxide, are delivered as gases. But many of the inhaled anesthetics used in modern anesthesia, including sevoflurane and isoflurane, are liquids at room temperature.

Before they reach the lungs, they have to be turned into vapor.

That is what the vaporizer does.

The vaporizer sits on the anesthesia machine and adds a controlled amount of anesthetic vapor to the fresh gas flowing through the system.

For most modern vaporizers, some of the gas passes through a chamber that contains the liquid anesthetic. As it moves through that chamber, it picks up anesthetic vapor. That vapor then rejoins the rest of the fresh gas flow before traveling through the breathing circuit to the patient.

When I change the vaporizer dial, I am changing how much anesthetic vapor is added to that gas mixture.

This is more engineered than it looks. Liquid anesthetics do not evaporate the same way under every condition. Temperature, pressure, flow, and the properties of the anesthetic itself all affect vapor output. Modern vaporizers are built to compensate for those variables so the delivered concentration stays predictable.

Desflurane is the unusual one. Its boiling point is close to room temperature, and its vapor pressure is high, so it requires a heated, pressurized vaporizer rather than the standard design.

Why the Dial Isn’t What Your Body Gets

One thing that is not obvious from the outside is that when I turn the vaporizer dial, the change does not instantly appear in the patient’s lungs.

The gas still has to move through the machine, travel through the breathing circuit, mix with gas already in the system, and reach the patient. At the same time, the patient’s body is continuously taking up an anesthetic.

This is where fresh gas flow matters. Higher flows usually make changes happen faster. Lower flows usually make changes happen more slowly. The size of the machine and the breathing circuit also matter. If there is more gas already sitting in the system, it takes longer for a change at the dial to fully reach the patient.

This is why anesthesia is not managed by dial setting alone.

We watch what the patient is breathing in. We watch what the patient is breathing out. We watch oxygen, carbon dioxide, ventilation, airway pressure, blood pressure, heart rate, surgical stimulation, and how the patient is responding over time.

The dial is one control. It is not the whole picture.

What the Machine Is Really For

At the highest level, the anesthesia machine exists to make anesthetic delivery controlled, measurable, and adjustable.

It gives us a way to deliver oxygen, add inhaled anesthetics, support or control breathing, remove carbon dioxide, and measure what the patient is breathing in and breathing out.

But the machine does not manage the anesthetic by itself.

The machine provides the equipment and the measurements. The patient’s body provides the physiology. The anesthesia provider has to interpret what is happening and decide what to do next.

That is the part that is easy to miss from the outside. The anesthesia machine is not just a collection of tubes, dials, screens, and alarms. It is a system we use continuously throughout a case to make decisions.

Next Week

Next week, I’m going to get into the safety systems built into the anesthesia machine: the alarms, the machine checks we do before the day starts, and the shorter checks we repeat before every case.

This is where the machine gets even more interesting. It is not only designed to deliver oxygen, anesthetic vapor, and ventilation. It is also designed to help us detect problems early — before they become emergencies.

If you have questions about how the anesthesia machine works, leave them in the comments.

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I have been a pediatric CRNA for 15 years. I love pediatric anesthesia. I love the little patients, the math I have to use to calculate their dosages, and the tiny supplies I navigate. It’s challenging, the patients are cute, and I could not imagine doing anything else as a CRNA.

I also know what a huge responsibility I have each time I take someone’s kid, whether an infant or an 18-year-old, to the operating room (OR). As a parent, you have to give your full trust to a stranger to take care of your child. Most parents have no clue what happens after we take their kid back to the OR. Let me give you a little insight.

Phase 0: Preoperative Sedation (The “Giggle Juice”)

Before we even head back to the bright lights of the operating room, our goal is to keep your child as calm and comfortable as possible. This is where we frequently collaborate with Child Life Specialists, dedicated pediatric healthcare professionals trained in child development who use play, education, and psychological preparation to help kids understand their procedures in a developmentally appropriate way.

One of the most effective non-pharmacological tools we use to combat preoperative anxiety is digital distraction. Engaging a child with an interactive game on a tablet, showing them their favorite cartoon on a smartphone (I’m pretty partial to Bluey), or even using virtual reality can profoundly redirect their attention away from the unfamiliar hospital environment. Studies have actually shown that using active tablet-based distractions or virtual reality can be just as effective at reducing preoperative anxiety as traditional sedative medications, and sometimes lead to smoother anesthesia induction and faster postoperative recovery.

If a child is exceptionally anxious or too young to benefit from digital distraction, we often give them a little something extra to help them relax. We call it preoperative sedation, and the most common medication we use is an oral liquid called midazolam (Versed). Kids often call it “giggle juice” or “silly syrup.” This medication does two wonderful things:

• It significantly reduces separation anxiety, making it much easier for the child to leave their parents

• It provides excellent anterograde amnesia—meaning they likely won’t remember the trip to the OR or leaving their caregivers.

Phase 1: Going to Sleep (Induction)

Once we’re in the OR, the first step in any anesthetic plan is induction—the process of safely transitioning a patient from awake to asleep. For most adults, this involves placing an intravenous (IV) line and administering medication directly into the bloodstream. In pediatrics, we have a much gentler option: the mask induction.

Children are understandably anxious about needles. We typically avoid placing an IV while they are awake, and instead, use a specialized breathing mask. We let the child pick a flavor for the inside of the mask (like bubblegum, strawberry, or watermelon). We also turn it into a game, asking them to practice being an astronaut by putting on a space mask or blowing up a giant imaginary balloon. As they breathe the sweet-smelling anesthetic gas, they drift off to sleep within a minute or two.

Once the child is fully asleep in the OR and unaware of their surroundings, we step in to safely place the IV and all the monitors to watch their vital signs during the procedure. We give medications to facilitate the placement of an airway device, such as an endotracheal tube or subglottic airway, to help protect and maintain their breathing while they are asleep.

Phase 2: During Surgery (Maintenance)

Once they are safely asleep, the surgical procedure begins. This phase is known as maintenance, and this is where my love for math and the tiny supplies really comes into play.

In my role mentoring and educating Resident Registered Nurse Anesthetists (RRNAs), I constantly emphasize that children are not just tiny adults. Their physiology, anatomy, and pharmacology are entirely unique. In adults, medication doses are somewhat standard. In pediatrics, every single medication, fluid drop, and breathing tube is meticulously calculated based on the child’s exact weight in kilograms.

A dose of pain medication for a 5-kilogram infant is vastly different from a dose for a 40-kilogram teenager. The mental workload and calculations required during this phase are substantial. In fact, ensuring this level of mathematical precision is so important to me that I developed a pediatric anesthesia calculator app to help practitioners manage these complex formulas accurately on the fly.

While the surgeon is entirely focused on the operation, the anesthesia provider’s sole focus is on your child. We continuously monitor their vital signs— heart rate, blood pressure, oxygen saturation, and temperature. Children lose body heat much faster than adults, so we utilize forced-air warming blankets and specialized fluid warmers to keep their core temperature stable. We adjust the depth of anesthesia second by second, ensuring the child remains entirely unaware, comfortable, and perfectly stable throughout the procedure.

Phase 3: Waking Up (Emergence)

As the surgeon finishes their work, we transition into the emergence phase. We turn off the anesthetic gases and begin administering pure oxygen. Long before the surgery ends, we have already executed a comprehensive, multimodal pain management plan. This might include intravenous acetaminophen, local numbing medicine applied by the surgeon, or specialized nerve blocks. Our goal is to ensure the child has a strong foundation of pain control on board before they even open their eyes.

Waking up from anesthesia can sometimes be disorienting for a child. Occasionally, they may experience “emergence delirium,” a temporary state in which they wake up crying, thrashing, or seemingly confused. While this can be difficult for parents to witness in the recovery area, it is simply a byproduct of the anesthetic gas clearing from their brains. It does not necessarily mean they are in pain; they are just caught in a twilight state between being deeply asleep and fully awake.

We monitor the child closely in the Post-Anesthesia Care Unit (PACU) until their breathing is regular, their vital signs are perfectly stable, and they are fully awake. We also know the most comforting thing for a child in an unfamiliar environment is a familiar face, so we work swiftly to reunite them with their parents as soon as it is clinically safe.

The Weight of Trust

Handing your child over for surgery requires immense vulnerability. When I take your child through those double doors, I carry that weight with me. Behind the surgical drapes is a highly trained, deeply vigilant professional focused on nothing else but bringing your child back to you safely.

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Thanks to Becky for this insider look at pediatric anesthesia. Subscribe to The Art of Anesthesia for weekly posts breaking down what happens in the OR—perspectives you won’t find anywhere else. New posts every Thursday. It’s free.

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About the Author

Becky Motykiewicz, DNAP, CRNA, is a pediatric nurse anesthesiologist with 15 years of clinical experience. She currently serves as a full-time Assistant Professor in a nurse anesthesia program and practices clinically in Philadelphia, where she is dedicated to evidence-based curriculum design and researching system-level interventions for healthcare burnout. Passionate about making education accessible through multiple modalities, she is also the developer of an app for a pediatric anesthesia calculator.

Connect with her on LinkedIn and Instagram.

I’m rolling my patient into the recovery room. They open their eyes and, slightly confused, ask when we’re going to start the surgery.

That’s the moment I know I did my job right.

People ask me all the time why I became a CRNA. They often expect me to say something about the science, the technical skills, or the high-stakes moments.

And yes, all of that is part of it. I love the physiology of anesthesia. I love that the work is technical, cerebral, and hands-on at the same time. I love that you have to understand what is happening in the body and also be able to act quickly when the body does not respond the way the textbook said it would.

But the real reason I moved across the country, quit my job, and went back to school for two and a half years was because I wanted to take care of one person at a time.

To get into CRNA school, I had to describe my motivations for choosing this career. The majority of those reasons still stand, but like anything in anesthesia (and in life), the more you learn, the more you find out how little you know.

It’s Incredibly Humbling (Every Single Day)

You will assess a patient, make a plan based on their medical history and surgery, and execute everything perfectly. And, you will still find yourself waiting 30 minutes after the surgery is done for the patient to wake up, while the entire room is staring at you, wondering what’s taking so long.

In those moments, when it’s clear nothing is wrong, but things are taking longer than expected, I’ll often tell people to pull up a chair and chat. Because there’s not much else to do except wait.

There are moments in anesthesia when you can feel like a superstar (for example, when you get a super difficult IV start, or make a tough airway look easy). But those moments are balanced by just as many reminders that it’s better to be lucky than good.

I Love the Team Environment of the OR

I have always loved team sports. Even when I played tennis in high school, I always played doubles. One of the best parts of working in the Emergency Department in my first job as a nurse was working closely with the care team.

That is what makes the OR so special, too. The chance to bring different perspectives, learn others’ strengths, and work toward a very specific common goal is rare, especially in medicine, where work can be siloed (to the point where I often attend out-of-state conferences to meet people at my own institution).

I particularly love working in smaller hospitals where I can get to know everyone well. I know how the surgeons approach their cases, how long a physician assistant will take to close, and even everyone’s favorite music.

But I also love the time between cases or during long surgeries when there is time to actually talk. Those conversations build the trust you need to speak up and make difficult calls when a situation gets tough.

Anesthesia Is Really About “Vibes”

I’ve heard it described differently, but everyone who delivers anesthesia understands this: you get very attuned to your patient.

It’s one of those things you can’t really teach from a textbook. You develop this intuition over years of practice.

When you give a dose of pain medication or make a small change to the anesthetic, you watch how the patient’s heart rate changes, and you can tell just by the sound of the monitor before the number even updates on the screen. You watch the patient’s blood pressure and respiratory rate, and you start to get a sense of how they are doing and what they need.

This is most important during emergence (when the patient is waking up). It is a tricky time when you have to make a lot of decisions quickly, and that intuition—that sense of how the patient is responding—becomes critical.

I can’t fully explain it. But after years of doing this, I just know.

The Honor of Taking Care of Someone

I’ve heard some people talk about anesthesia as almost a spiritual or religious calling, and there are absolutely elements of that.

When you have surgery, it is your anesthesia provider who never leaves the room, or even your side, from the beginning until they drop you off in the recovery room. And we take that responsibility incredibly seriously.

We make sure everything is right. The positioning, temperature, and even making sure your lips don’t get dry. If someone gets too close to a patient’s face or moves an arm in a way I don’t like, they will hear from me. And don’t even think about touching the remote that unlocks or moves the bed.

I’ll tell the room to be quiet as the patient is going to sleep and waking up. I want the first thing a patient hears when they wake up to be a calm, reassuring voice saying, “Your surgery is all done. Everything went great. You are waking up from surgery. Take some big deep breaths.”

The Privilege of Caring for One Patient at a Time

When I was an ER or ICU nurse, I often felt pulled in so many directions. But in the OR, delivering anesthesia, I get to focus on one patient. I make the plan. I give exactly the anesthesia I want. I tailor every decision to make the experience as good as possible for that person.

And that is really where the art of it comes into play, which is what I absolutely love.

It is the delicate balance of making sure the pain is controlled, but not making the patient too sleepy so they can get up and move as soon as possible after surgery. It is taking into consideration their other medical conditions and what they are at highest risk for— whether that’s nausea, a sore throat, or something more serious like a stroke—and tailoring every single decision to reduce that risk.

All while also keeping them calm and quickly gaining their trust.

And it is such a wonderful feeling when a patient wakes up peacefully, says they have no pain, and is shocked to hear the surgery is already done.

Most of the time, they don’t even remember meeting us, which is actually a wonderful outcome. It means we managed to make something feel normal on what was probably one of the most stressful days of their life.

If this resonated with you, share it with someone who’s curious about what actually happens in the OR. And if you’re not subscribed yet, you can get posts like this in your inbox every Thursday—breaking down anesthesia, surgery, and what really happens behind the scenes.

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After sharing the earlier posts in this series, I received several questions asking for more detail—why I chose it, what the experience was actually like, whether I felt like I missed out on anything, whether it affected bonding or breastfeeding, and whether I would make the same decision again.

So I thought it made sense to share more of the thinking behind my decision, not as a recommendation for anyone else, but as an explanation of how I approached it and why I ultimately feel like I had one of the best birth experiences I could have imagined.

This is Part 4 of a 4-part series on anesthesia and childbirth. I was planning to do a traditional Q&A for this finale, but the most common question I received throughout the series was: “Why did YOU choose a C-section?” So instead of hot topics and complications, I wanted to address that directly.

How I Approached the Decision

In the same way that I approach patient care, I wanted to evaluate the decision based on safety first, then comfort, and then the actual lived experience. And because I am me, I also wanted to understand the literature. I did not want to make a decision based only on fear, secondhand stories, or on the cultural expectation that there is a “right” way to give birth.

The literature on elective C-section by maternal request is not as simple as people often make it sound. ACOG (the American College of Obstetricians and Gynecologists) does not recommend elective C-section as the default mode of birth in the absence of a medical indication, but it also recognizes that cesarean delivery on maternal request is a legitimate patient decision and should involve individualized counseling about maternal risks, neonatal risks, future pregnancy implications, and the patient’s values.

ACOG also states that if a cesarean delivery on maternal request is planned, it should not be performed before 39 weeks in the absence of another indication.

NICE (the UK’s National Institute for Health and Care Excellence) takes a similarly patient-centered approach: pregnant people should be given information and support to make informed decisions, and after informed discussion, a maternal request for cesarean birth should be taken seriously rather than dismissed.

The Long-Term Consequences I’d Seen

I first started thinking about this because of my grandmother. I was very close to her, and became very involved with her medical care until she passed away at the age of 97. She was remarkably active in mind and body until the last few months of her life.

One of the biggest issues she struggled with later in life was severe urinary dysfunction. It caused repeated infections, discomfort, and distress. It affected her quality of life in a way that many people may not appreciate unless they have witnessed it first hand with a loved one, or experienced it themselves.

Pelvic floor injury, urinary symptoms, prolapse, incontinence, and bowel dysfunction are not minor inconveniences. They are not just things women are supposed to quietly tolerate because they had a baby. They can be life-altering and can shape how someone feels in her body for decades.

The data support that these issues are common and long-lasting. A large long-term cohort study published in BJOG followed women more than 20 years after childbirth and found that pelvic floor symptoms remained highly prevalent decades later. Women who had only cesarean births had the lowest reported rates of urinary incontinence, fecal incontinence, and prolapse symptoms.

That does not mean a C-section “prevents” pelvic floor dysfunction. Pregnancy itself affects the pelvic floor, and factors like age, body weight, genetics, fetal size, and operative delivery all play a role, and this is why the study above found pelvic floor symptoms amongst everyone who had experienced pregnancy. I therefore would never suggest that a C-section simply lets someone avoid pelvic floor problems. But, it is equally disingenuous to talk about pelvic floor injury as though it is trivial, rare, or merely cosmetic. It is none of those things.

For me, having seen the long-term consequences in someone I loved became part of the risk-benefit conversation.

My Clinical Experience Mattered

The other major piece was my clinical experience. I had seen beautiful vaginal births and calm, controlled C-sections. I had also seen the other side. I had seen labors that went on for days. I had seen exhausted patients trying to make decisions after being in pain for hours without having slept or eaten. I have seen emergent C-sections where seconds mattered.

As an anesthesia provider, that mattered to me. A scheduled C-section at 9 a.m. is a very different clinical situation than an emergent C-section at 2 a.m. after three days of labor. The same operation may happen in both scenarios, but the conditions are not the same.

In a scheduled case, the team is ready. The surgeon is ready. The anesthesia team is ready. The room is set up. The patient is awake, rested, and able to participate in the plan. There is time to place the spinal carefully, test the block thoroughly, and move in a controlled way.

I wanted the room to be as calm as possible. I wanted the surgeon to be operating under the best possible conditions. I wanted the anesthesia plan to happen before anyone was rushed.

Weighing the Risks

That is not because vaginal birth is unsafe. It is not. And it is not because planned C-sections have no risk. They absolutely do.

A C-section is major abdominal surgery. It carries risks of bleeding, infection, injury to surrounding structures, blood clots, adhesions, and implications for future pregnancies. ACOG specifically emphasizes that counseling should include future reproductive plans because repeat cesareans increase risks such as placenta previa (when the placenta covers the cervix) and placenta accreta spectrum (when the placenta grows too deeply into the uterine wall).

It’s not a casual choice, and it’s not a shortcut. It’s definitely not “the easy way out.”

But when I weighed the risks, I was not only thinking about the operation itself. I was thinking about the entire clinical journey. I was thinking about the possibility of prolonged labor, the possibility of needing an urgent C-section anyway, the possibility of pelvic floor injury, and the possibility of ending up with both a long, exhausting labor and major abdominal surgery at the end of it.

Birth Is More Than the Mode of Delivery

With my C-section, I had a nice dinner the night before. I slept well. I woke up, showered, and went to the hospital feeling clear-headed. I was not contracting. I was not exhausted. I was not scared from hours of pain or uncertainty. I had time to talk to my anesthesia team. I knew the plan. The spinal went in, the block worked, and I was awake, calm, and present.

And when my baby was born, I was not depleted. I was able to hold him. I was able to take in the moment. I was able to breastfeed without issue. I was comfortable enough to be emotionally present.

I think we severely downplay the effects of a traumatic birth. We talk about “healthy mom, healthy baby” as if that is the only endpoint that matters. And yes, of course safety matters. Of course a healthy baby matters. But the experience matters too. Feeling terrified matters. Feeling unheard matters. Feeling pain during surgery matters. Feeling like things spiraled out of control matters. Being so exhausted by the time the baby arrives that you can barely process what just happened matters.

The literature supports this too. A 2025 systematic review and meta-analysis on postpartum PTSD found that PTSD prevalence after emergency C-section ranged from 2.2% to 41.2%, compared with 0% to 20% after elective cesarean birth. The odds of PTSD were significantly higher after emergency C-section.

A 2024 study also found that unplanned or emergency cesarean delivery was associated with higher postpartum PTSD symptoms, which aligns with what many of us see clinically: the emergency itself, the loss of control, the fear, the pain, the urgency, and the way communication happens in that moment can all shape how someone remembers the birth.

Every Pathway Has Risks

This is where I think the conversation often gets flattened. People will say, “But C-sections have risks,” as if that ends the discussion. Of course they do. But every pathway has risks. Vaginal birth has risks. Operative vaginal birth has risks. Prolonged labor has risks. Emergency surgery has risks. General anesthesia in pregnancy has risks.

The real question is not, “Which option has no risk?” because that option does not exist. The real question is, “Which risks matter most to this patient, in this body, with this pregnancy, in this clinical context, after a real informed consent conversation?”

I chose a C-section because I had spent years in operating rooms, years watching what happens when plans change quickly, and years understanding that “natural” does not always mean safer, gentler, or more humane. Sometimes the most controlled plan is the most humane plan.

That was what I wanted. And that was what I had.

It’s Okay to Choose Differently

I know not everyone will feel that way. Some people deeply want the experience of labor a and I understand that completely. For many people, that is meaningful, empowering, and beautiful. I also know that many people have unplanned C-sections and still have very positive, supported births.

But it is also okay for someone to look at the same set of options and choose differently. It is okay to say, “I want the most controlled environment possible.” It is okay to say, “I am prioritizing predictability.” It is okay to say, “I understand the risks of surgery, and after thinking through the alternatives, this still feels like the right choice for me.”

Because birth is not a performance. It is not a test of endurance. It is not something anyone should have to justify to strangers.

For me, an elective C-section was the right decision. I had a calm birth. I had a safe birth. I had a baby placed into my arms while I was rested, present, and able to take in the moment.

That’s the end of the Anesthesia and Birth series. Thank you for following along. If you missed any posts:

• Part 1: Epidurals for Labor

• Part 2: Spinals for C-Sections

• Part 3: General Anesthesia for Birth

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One patient still sticks with me. We were trying to intubate a woman who had been laboring for three days. We tried to strengthen her epidural for surgery, but it didn't work, and we had to move quickly to general anesthesia. Her airway was swollen from prolonged labor and fluid shifts. I got the tube in, the baby was delivered, everyone was okay—but it was close.

Labor and delivery is one of the most dynamic areas of anesthesia. And I have so much respect for the anesthesia professionals who do this work.

Even when the plan is a spinal. Even when the epidural should work. Even when the patient is awake, talking, and breathing on their own. We still have to be ready to convert to general anesthesia at any moment.

Most of the time, we will not need to.

But when we do, the situation often changes quickly. And in obstetrics, “quickly” can mean there is very little time to troubleshoot, deliberate, or slowly build a new plan. The team has to move with precision because now we are caring for two patients at once: the person giving birth and the baby who needs to be delivered safely.

For the women I know who have needed general anesthesia for an emergency C-section, it is often frightening and disorienting on top of an already intense experience. One moment they are awake and aware, and then suddenly the room changes. People move faster, and medications are given quickly. We are often literally running down the hall (one of the only times we actually do that, despite how often they show it happening in the TV shows).

The whole experience can be very traumatic, even when it ends with a safe delivery and a healthy baby.

So in this part, I want to explain what general anesthesia for a C-section actually means, why we try to avoid it when we can, and why sometimes it becomes the safest choice.

This is Part 3 of a 4-part series on anesthesia and childbirth. In Part 1, I covered epidurals for labor. In Part 2, spinals for C-sections. Today: general anesthesia for birth—when we use it, why we try to avoid it when we can, and what actually happens when it becomes necessary. If you have questions, drop them in the comments—I’ll answer them in Part 4.

Why We Avoid General Anesthesia When We Can

The simple answer is: because a spinal or epidural usually allows us to avoid the highest-risk parts of general anesthesia in pregnancy.

With a spinal or epidural, you can stay awake, breathe on your own, protect your own airway, and still have complete surgical numbness. That is why neuraxial anesthesia — meaning spinal, epidural, or combined spinal-epidural anesthesia — is the preferred approach for most C-sections. That is also why spinals and epidurals are used for more than 95% of elective and even 80% of emergent C-section deliveries in the US.

That does not mean general anesthesia is wrong. It means we use it when the benefits outweigh the risks.

And in pregnancy, the risks are different.

The First Concern: The Airway

Pregnant patients are not just “regular anesthesia patients who happen to be pregnant.” Pregnancy changes the body in ways that matter deeply for anesthesia, especially when we are talking about general anesthesia and the airway.

By the end of pregnancy, the airway (like most other parts of the body due to the dramatic increase in blood volume) becomes swollen. The tissues in the mouth, nose, throat, and around the vocal cords can also become more vascular, meaning they may bleed more easily if they are irritated. Even small amounts of swelling or bleeding can matter when we are trying to place a breathing tube quickly and safely.

Positioning can also be more difficult. The enlarged abdomen changes how the body lies on the operating room table, and the breasts can make it harder to position the laryngoscope, which is the instrument used to help place the breathing tube. These small details are critical in airway management.

Pregnant patients use more oxygen, but they also have less reserve in their lungs because the enlarged uterus pushes up on the diaphragm and reduces functional residual capacity, which is essentially the amount of air left in the lungs after a normal breath. So once a pregnant patient is asleep and not breathing on their own, oxygen levels can fall faster than if they were not pregnant.

The Second Concern: Aspiration

Aspiration means stomach contents come back up and enter the lungs. This can cause serious lung irritation, difficulty breathing, pneumonia, or even life-threatening lung injury. It is one of the reasons anesthesia providers ask so many questions about when you last ate or drank, whether you feel nauseated, and whether you have reflux.

It is also one of the reasons many hospitals limit what you can eat during labor.

The concern is what might happen if labor suddenly becomes an urgent C-section and general anesthesia is needed. Once someone is under general anesthesia, they lose the normal protective reflexes that help keep stomach contents out of the lungs.

Pregnancy and labor increase this risk. The enlarged uterus pushes up on the stomach. Labor pain, stress, and opioid medications can slow stomach emptying even further.

This is why anesthesia guidance generally allows modest amounts of clear liquids for uncomplicated laboring patients, but recommends avoiding solid foods during labor. For scheduled C-sections, patients are typically asked to fast from solid foods for 6–8 hours, depending on the type of food, and clear liquids may usually be allowed until about 2 hours before anesthesia.

The Third Concern: The Baby

General anesthesia medications can cross the placenta. The longer the time between starting general anesthesia and delivery, the more the baby is exposed to those medications.

Recent research shows that babies born by C-section under spinal or epidural anesthesia, or combined spinal-epidural anesthesia, tend to do slightly better in the first few minutes after birth compared to babies born under general anesthesia.

A recent meta-analysis found that spinal or epidural anesthesia was associated with slightly higher Apgar Scores1 (a measure of how well the baby is doing right after birth) and less need for breathing support right away. However, the rates of babies needing NICU admission were about the same.

General anesthesia is often used in the sickest, fastest-moving, most urgent cases. It may be used when there is fetal distress, severe bleeding, maternal instability, a failed epidural or spinal, or simply not enough time to safely place neuraxial anesthesia.

So, when we see a study on worse neonatal outcomes associated with general anesthesia, we should be mindful of a hidden variable: part of the retrospective relationship may be related to anesthesia exposure, but there may also be other causes, like the reasons the general anesthesia was needed in the first place.

When we can safely avoid it, we usually prefer to. Regional anesthesia lets us avoid airway manipulation, reduce aspiration risk, keep the mother awake and breathing on her own, and may also be associated with a modestly better early newborn transition.

The Fourth Concern: The Birth Experience

When you have a spinal or epidural for a C-section, you are awake. You may feel pressure, pulling, tugging, and movement, but you are present. You can hear the baby cry. You can usually have a support person in the room. You can remember the birth.

With general anesthesia, that changes.

You are unconscious. A breathing tube is placed. Your support person may not be allowed in the operating room, depending on the urgency and hospital policy. Your first memory may be waking up in recovery and being told the baby has already been born.

For some people, especially when general anesthesia happens during an emergency, that can be emotionally difficult. A recent review found that general-anesthetic cesarean birth can affect maternal mental health, childbirth experience, and bonding, although the research base is still limited.

We need to be doing more research on these experiences and developing interventions to help women through these types of experiences.

Why We Prepare So Carefully

Every C-section has an anesthesia plan. But it also has a backup plan. And a backup plan to the backup plan. That is especially true in pregnancy because things can change quickly.

And that is what I wish more people understood about anesthesia for birth. It is not just about being awake or asleep. It is not just about spinal versus epidural versus general anesthesia. It is about constantly balancing risks in real time while caring for two patients at once.

The best anesthetic is not always the one we hoped to use when the day started.

The best anesthetic is the one that keeps a patient and her baby safe when the moment changes.

Next week: Part 4 of Anesthesia and Birth—Your questions answered. Hot topics, complications, and everything else you’ve been wondering about.

Got questions about general anesthesia, spinals, epidurals, or anything else in this series? Drop them in the comments. I’ll answer them in Part 4.

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I know that may sound strange; many find the OR cold, intimidating, or frightening. To be fair, it can be all of those things. It is bright, sterile, loud (at times), and busy (almost all the time).

But, for me, the operating room has always felt like the place where things make sense.

I am comfortable there because I know where everything is, what the monitors mean, and what we are watching for. I love the team environment, the controlled chaos, and the way people in the room each have a different job while still moving toward the same goal.

During surgery, there are moments when the room is all business. But there are also moments when the surgical team talks, and I love those moments. We talk about the latest reality show, politics, kids, vacations… These are people I spend ten, twelve, sometimes even sixteen hours a day with. They know the details of my life in a way that sometimes feels more intimate than people I see socially.

So when I became pregnant, I did what many people do: I asked the people around me about their birth experiences. And the people around me happened to be surgeons, physician assistants, nurses, obstetricians, and people who had seen birth from a very specific angle.

And through those conversations, I made a clear decision: I wanted to have a C-section.

This is Part 2 of a 4-part series on anesthesia and childbirth. In Part 1, I covered epidurals for labor. Today, I want to talk about spinals for C-sections: what they are, how they work, what you actually feel, and what the anesthesia provider is doing while you are awake in the operating room. If you have questions along the way, drop them in the comments—I’ll answer them in Part 4.

What Anesthesia Looks Like During a Planned C-Section

Which brings me to what the anesthesia usually looks like during a planned, controlled C-section.

The most common type of anesthesia is a spinal anesthetic.

A spinal is a type of neuraxial anesthesia, which means the medication is placed near the nerves of the spine to create numbness—not given through an IV to make you unconscious. The goal is not to put you to sleep, but to create surgical anesthesia: a dense, reliable numbness strong enough for abdominal surgery, while allowing you to stay awake, breathe on your own, and be present for the birth.

This is different from a labor epidural. With an epidural, a small catheter is left in place so medication can be continuously infused and adjusted over time. A spinal is different. With a spinal, medication is given as a single injection into the cerebrospinal fluid (the clear fluid that surrounds the spinal cord and spinal nerves). A spinal works quickly, densely, and predictably.

That is why spinals are so commonly used for planned C-sections. They are fast, reliable, and, when they work the way they are supposed to, they allow the patient to be awake without feeling surgical pain.

How a Spinal Is Placed

The process looks somewhat similar to epidural placement (at least from the patient’s perspective).

You are usually sitting up on the operating room table, or occasionally lying on your side. The anesthesia provider helps you curl forward to open the spaces between the bones of the lower spine. Your lower back is cleaned in a sterile fashion, and then the skin is numbed with a local anesthetic. This might sting or burn briefly, which is usually the most uncomfortable part.

Then a very small spinal needle is placed between the bones of the lower back, below where the spinal cord ends. Once the needle is in the right place, medication is injected into the spinal fluid. The needle is removed. Unlike an epidural, there is no catheter left behind.

Your legs may start to feel warm, heavy, tingly, or strange. Some people describe it as their legs “disappearing.” That is the spinal taking effect.

For a C-section, the numbness has to rise high enough to cover pain from the uterus, abdominal wall, and peritoneum. Before surgery begins, the anesthesia provider tests the numbness carefully—checking whether you can feel cold, sharpness, or dullness at different levels of the body.

This matters because pain and temperature fibers are usually blocked before deeper pressure sensations are completely gone.

That is why you should not feel sharp surgical pain, but you may still feel pressure, pulling, movement, or tugging.

What You’ll Actually Feel

A C-section under spinal anesthesia should not be painful.

But it also usually does not feel like nothing.

That is the part I think we don’t always explain clearly enough. Patients are often told, “You’ll feel pressure.” While that is true, it does not fully prepare someone for what that pressure may feel like.

During the surgery, especially when the baby is being delivered, there can be a lot of movement. The surgical team is moving tissue, applying pressure, and working inside the abdomen. The baby does not simply float out. There is often pushing, pulling, rocking, and pressure.

Some people feel tugging. Some feel stretching. Some feel like their body is being moved around even though they are numb. Some feel pressure high in the abdomen or under the ribs. Some feel nauseated or lightheaded, which can be related to blood pressure changes, surgical stimulation, or both.

None of these sensations automatically mean that the spinal is not working.

A recent study (published April 2026) found that intraoperative pain during C-sections under spinal anesthesia occurred in about 6% of patients. The risk was higher when the spinal block did not rise high enough or when surgery lasted longer. Patients who experienced pain during surgery also had higher rates of postoperative pain and postpartum depression.

Now, that study was about non-elective C-sections (not scheduled C-sections like mine), so we should be careful not to apply it too broadly.

However, sharp, burning, or cutting pain—or any pain that feels intolerable—should be taken seriously immediately.

What the Anesthesia Provider Is Managing

When people think about anesthesia, they often think about the moment the medication is given. But during a C-section, the spinal is only the beginning.

Once the spinal starts working, the anesthesia provider is continuously managing physiology.

One of the most important effects of spinal anesthesia is something called sympathectomy. That means the spinal temporarily blocks part of the sympathetic nervous system, which is the system that helps maintain blood vessel tone. When those blood vessels relax, blood pressure can drop. This is expected. It is also one of the reasons we watch so closely.

A drop in blood pressure can make you feel nauseated, dizzy, weak, sweaty, short of breath, or like something is wrong. And because this is birth, we are not only thinking about the patient’s blood pressure in isolation. We are also thinking about blood flow to the uterus and placenta before the baby is delivered.

While the surgical team is focused on the operation, the anesthesia provider is focused on you. We are watching the blood pressure, heart rate, oxygen level, breathing, nausea, anxiety, comfort, bleeding, uterine tone, and the delivery timing.

If your blood pressure drops, we treat it, often with IV medication, fluids, and/or positioning. If you feel nauseated, we treat that too. If you are itchy from the spinal medication, we can treat that. If you are shaking (very common during C-sections), we can help with that. If you feel anxious, we talk you through it and, when appropriate, give medication.

And if you feel pain, we need to know. Because when you say something, we respond.

Being Awake in the OR

One of the strange things about a C-section is that you are awake for surgery.

Most patients come into the OR, receive anesthesia, and then wake up when the procedure is over. A C-section is different. You are there. There is a drape, so you are not watching the surgery itself. But you are aware of the room. You hear people talking. You may hear the baby cry. You may feel your support person next to you. You may feel disconnected from the lower half of your body and intensely aware of everything above the drape.

For some people, this is beautiful. For some people, it is overwhelming. For many people, it is both.

That is why communication matters so much. The anesthesia provider is often the person narrating the experience from the head of the bed. We tell you what is normal. We notice when your face changes, when your breathing changes, when you get quiet, when you start to look scared.

There is a lot of anesthesia that is technical. There is also a lot of anesthesia that is simply being close enough to notice.

The Bottom Line

In a planned C-section, spinal anesthesia is not simply “a shot in the back.”

It is a precise anesthetic designed to produce rapid, reliable surgical numbness while preserving consciousness, spontaneous breathing, and the ability to be present for the birth.

You may feel pressure, movement, tugging, pulling, or pushing. But you should not feel sharp surgical pain. And if you do, you should tell your anesthesia provider immediately.

You are allowed to speak up. You are not being difficult. You are not interrupting. You are not supposed to silently endure pain because someone told you it was normal.

Your anesthesia provider is there to manage both your safety and your experience. And for me, as someone who both gives anesthesia and has received it for birth, that is what made the operating room feel not frightening, but safe.

Next week: Part 3 of Anesthesia and Birth—General anesthesia for birth. When we use it, why we try to avoid it, and what actually happens when it’s necessary.

Got questions about spinals, C-sections, or anything else in this series? Drop them in the comments. I’ll answer them in Part 4.

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This procedure can be done by either a CRNA or an anesthesiologist. And whether you are planning to get an epidural or not, understanding what it actually is—what it does, how it works, and what the risks are—helps you make an informed choice.

This is Part 1 of a 4-part series on anesthesia and childbirth. Over the next few weeks, I’ll cover epidurals for labor, spinals for C-sections, general anesthesia for birth, and answer your questions about complications and alternatives. If you have questions along the way, drop them in the comments! I’ll address them along the way.

Informed Consent (and Why Timing Matters)

Any time you have a significant medical procedure, you need to complete an “informed consent.” That means the risks, benefits, and alternatives are explained, and you, as a patient, make an informed decision about whether to proceed.

For labor epidurals, in theory, this conversation happens before the epidural is placed.

In reality? During labor, some patients only speak to the anesthesia provider when their contractions are two minutes apart, with their pain at a 12 out of 10.

Is that actual informed consent? Is the patient able to understand the steps of the procedure, the possible risks, and the alternatives when she is in that much pain?

I have had friends consent to epidurals in those circumstances who told me they didn’t remember if their anesthesia provider was male or female, let alone the details of the consent conversation.

That is why, in my opinion, all patients should speak to an anesthesia provider about epidurals when they arrive at the hospital, whether or not they plan to get one. Having that conversation before the pain becomes overwhelming gives them the chance to make a truly informed choice if circumstances change.

What an Epidural Actually Is

An epidural is the most common (and most effective!) form of pain relief used during labor.

It works by placing a very small catheter into the epidural space in the lower back. Nerves in this region of the body carry pain signals from the uterus, cervix, and birth canal up to the brain. Medication is then delivered through the catheter—either continuously or in carefully controlled doses—to reduce those pain signals.

Labor pain is not just “intense discomfort.” It is a real physiologic process involving uterine contractions, cervical dilation, pressure, stretching, and nerve transmission. Early labor pain is carried mostly through nerves from the uterus and cervix, while later labor and delivery involve additional pelvic and perineal nerves.

An epidural works by bathing those nerves with medication—usually a combination of a local anesthetic and a small amount of opioid—so the pain signals are dampened before they fully register.

The goal is not to make you unconscious or completely numb.

This is a common misunderstanding. A labor epidural is designed to provide pain relief while allowing you to stay awake, alert, and part of the experience. Most people still feel pressure, movement, and the progression of labor, but the sharp pain of contractions is dramatically reduced.

Another important point: an epidural is not a single injection “into the spine.” It is a catheter that stays in place, which means the medication, rate, or dosage can be adjusted as the situation changes. This flexibility is one of the reasons epidurals are so useful to clinicians.

What Actually Happens When You Get an Epidural

First, we help you sit up or lie on your side and curl forward slightly. You’ll hear people describe the process “like a cat stretching its back.” The goal is to open up the spaces between the bones in your lower back so we can place the epidural safely.

We clean your back very carefully, typically with a swab. It’s a sterile procedure, so everything is done in a deliberate way to reduce the risk of infection.

Next comes a small injection of numbing medication in the skin. This part can sting or burn for a few seconds—similar to getting an IV—but it works quickly.

Once that area is numb, we use a specialized needle to find the epidural space. This is not going “into the spine;” the space is just outside of the spinal cord. You may feel pressure, but you shouldn’t feel sharp pain. The most important thing during this step is staying still, even if a contraction is happening (and we’ll help coach you through that).

After we find the right space, we thread a very thin, flexible catheter through the needle. Then the needle comes out, and the catheter stays in place. The catheter will allow us to give medication continuously and adjust the dosage as labor progresses.

We secure the catheter to your back with tape so it doesn’t move, and then we start the medication. Relief doesn’t happen instantly. The effect of the medication usually builds over 10–20 minutes as it begins to numb the nerves.

From that point forward, everything is adjustable. If you’re too numb, not comfortable enough, or feeling uneven relief, we can change the medication, reposition you, or troubleshoot the catheter.

The Benefits

An epidural has real benefits, and that is why many patients choose one.

The biggest benefit is obvious: it is the most effective pain relief we have for labor.

From a physiologic standpoint, good pain control in labor can do more than improve comfort. Severe pain increases stress hormones, heart rate, and blood pressure, and can make labor feel more exhausting and overwhelming. Reducing that pain can help your body feel less under siege and can make the overall experience more manageable.

And, if a cesarean section becomes necessary, an epidural that is already in place gives the anesthesia team a major head start. In the most urgent situations, what we talk about is time: how quickly we can get anesthesia ready so the baby can be delivered. A well-functioning labor epidural can often be converted so a baby can be delivered by c-section within minutes.

The Risks and Tradeoffs

Epidurals also have risks and tradeoffs, and everyone deserves a clear explanation of those too.

The most common issue is a drop in blood pressure. The medication blocks the nerves that help maintain blood vessel tone (the tension in blood vessels that keeps pressure stable). This can cause blood pressure to dip, and is one reason laboring patients are monitored so closely after placement.

Epidurals (or, more specifically, the medications that are administered through the epidural catheter) can also cause itching, shivering, or incomplete pain relief. Sometimes the block is “patchy”—meaning some areas are numb while others aren’t—or “one-sided,” where one side of your body gets more relief than the other. When that happens, we can make many adjustments to the catheter or the medication. Sometimes it works beautifully after adjustment. Sometimes the catheter needs to be replaced.

There are also less common but important risks.

A spinal headache (also called a post-dural puncture headache) can happen if the needle unintentionally goes a bit too far and punctures the protective layer around the spinal cord. We’ll talk more about this in Part 4, but it’s a known risk that’s part of the consent discussion.

Infection, bleeding, or nerve injury are much rarer, but they are possible with an invasive procedure and also a part of the consent conversation.

And while many people worry that an epidural will completely prevent movement or lead directly to a C-section, that is not supported by evidence or the goal of modern labor epidural practice. The goal is usually enough pain relief to make labor tolerable while preserving as much function and mobility as possible.

When an Epidural Is Recommended for Safety, Not Pain Relief

In some cases, anesthesia providers will strongly recommend getting an epidural even if you don’t plan to use it for labor pain.

This happens with extremely high-risk patients—patients where an emergency C-section is more likely or where general anesthesia would carry significant risks.

If an epidural is already in place, we can use it to provide surgical anesthesia (by converting it to what’s called a spinal-epidural or giving higher doses of medication through the existing catheter). This can help us avoid general anesthesia, which is safer for both mother and baby in most situations.

We’ll dive deeper into why we avoid general anesthesia for birth in Part 3.

The Bottom Line

Like any medical procedure, epidurals have risks, limitations, and tradeoffs. They are not the right choice for every patient or every situation.

But for many laboring patients, an epidural is a safe, effective, and highly refined way to treat one of the most intense forms of pain the human body experiences.

And understanding what it actually does—not just what people say about it—helps you make the choice that’s right for you.

Next week: Part 2 of Anesthesia and Birth—spinals for C-sections, how they’re different from epidurals, and what happens in the OR.

Got questions about epidurals? Drop them in the comments. I’ll answer them in Part 4 of the series.

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This week, let’s talk about something even more striking: there are literally no anesthesia providers in the show.

Now, to be fair, anesthesia doesn’t usually hang out in the ER. We are usually in the operating room or labor and delivery, not suturing wounds or triaging patients. But we absolutely get called to the ER —especially in “all hands on deck” emergency situations and almost always when intubation is difficult or high-risk.

And The Pitt has plenty of those moments.

Not to jump ahead of myself, but in particular, there’s a scene where they perform an awake fiberoptic intubation on an obese patient who can’t lie flat for a CT scan. That’s a procedure I would never expect to see done in an ER without anesthesia, and without an ENT surgeon standing by. And I will explain why later in this post!

The fact that anesthesia providers don’t exist in this world is a choice. And like the nursing erasure in Part 1, it sends a message: this work isn’t important or interesting enough to depict on screen.

So let’s jump into a few other anesthesia related observations!

The Ketamine Obsession

One thing that really stood out to me in Season 1 of The Pitt was the show’s heavy reliance on ketamine to sedate patients for intubation.

This is kind of wild.

After nearly 15 years in anesthesia and 20 years as a nurse, I have never personally witnessed ketamine used as the sole induction agent for intubation (I have seen and used ketamine for many other uses in the ER and OR–please keep reading for those!). The standard approach–especially in controlled settings–is Propofol and a neuromuscular blocker (for more on this, check out my First Minutes of General Anesthesia series). In a critically ill patient, we would turn to Etomidate, not Ketamine.

To be fair, the show isn’t entirely inaccurate. Ketamine has a well-established role in emergency and critical care and is an optimal choice in specific scenarios.

Here’s why: Ketamine is a dissociative anesthetic—technically an NMDA receptor antagonist—that blocks receptors in the brain responsible for processing pain and sensory input.

In emergencies, it can:

• preserve airway reflexes better than other sedatives

• support blood pressure rather than dropping it, and

• maintain respiratory drive more than propofol or benzodiazepines

These attributes make Ketamine especially useful in hemodynamically unstable patients, such as those with sepsis or trauma, or those who cannot tolerate a drop in blood pressure.

Recent literature supports ketamine for emergency intubation–mainly in the sickest, most unstable patients–but not as routine use as the show suggests. Even then, ketamine isn’t clearly safer than alternatives; it’s one option, not the default.

Part of the reason The Pitt might be leaning so hard into ketamine is that the drug is having a cultural moment. Ketamine has gotten significant press recently, both for its use in treating depression (specifically, an intranasal formulation called esketamine for treatment-resistant depression), and also for the growing conversation around “microdosing” for mental health.

But those are very different contexts—different doses, different monitoring, different goals—than using ketamine for procedural sedation or intubation in an emergency.

What Ketamine Actually Does (And Its Tradeoffs)

Ketamine doesn’t just sedate; it dissociates a patient, placing them in a state of detachment from their environment, often with hallucinations or altered perceptions.

I used ketamine many times in the ER for “conscious sedation”, especially in pediatrics. It was a great medication for painful procedures. Kids would describe being ‘in a waterfall with unicorns’ or other vivid but generally pleasant experiences.

But I never used it as the sole agent for intubation. That’s what makes The Pitt’s approach so striking—they are using it routinely for intubation, not just for conscious sedation or in the sickest, most unstable patients where it might be the best choice.

For adults, Ketamine’s hallucinations are usually less pleasant than the pediatric unicorn waterfalls. That’s why we often give ketamine alongside midazolam or another sedative to reduce the intensity of the dissociative experience and make it less frightening.

Ketamine also comes with tradeoffs:

• It can increase secretions (sometimes requiring suctioning)

• It raises the risk of nausea and vomiting

• Historically, it was thought to increase intracranial pressure (though current evidence suggests this isn’t as significant in controlled, ventilated patients as we once believed)

It’s a useful drug. But it’s not a magic bullet. And it’s definitely not the go-to agent for every intubation like The Pitt makes it seem.

The Awake Fiberoptic Intubation Scene: What Even Was That?

And then there’s the awake nasal intubation scene.

A patient, Howard, arrives in acute distress: obese, unable to lie flat, and too large for the CT scanner. He needs urgent imaging, but his condition is worsening. The team proceeds with an awake fiberoptic nasal intubation.

An awake fiberoptic intubation (a term that may be unfamiliar outside of anesthesia) is a technique in which a flexible scope is used to place a breathing tube while the patient remains conscious.

Under typical circumstances, intubation is performed after the patient is rendered unconscious with sedatives and muscle relaxants, allowing a breathing tube to be placed without discomfort or resistance.

An awake fiberoptic intubation differs in that the patient remains conscious while the airway is anesthetized locally. A flexible camera (fiberoptic scope) is then used to navigate through the nose or mouth and guide the breathing tube into position while the patient continues to breathe spontaneously.

This technique is reserved for patients in whom intubation is expected to be particularly difficult, e.g., those with abnormal airway anatomy, severe obesity, tumors, or other factors that make standard approaches high-risk or unfeasible. Howard fits this profile—his severe obesity and respiratory distress make him exactly the kind of patient for whom an awake fiberoptic might be appropriate.

But it’s a controlled, deliberate procedure, typically performed in the operating room with contingency plans in place, and often with an ENT surgeon immediately available in case things go wrong.

So here’s what doesn’t make sense about The Pitt scene:

Why do an awake fiberoptic in the ER (vs. the OR)? This is a high-risk procedure in a patient with a difficult airway. It is performed in a controlled environment—the operating room—with an anesthesia provider, full monitoring, and backup airway equipment immediately available, not in an emergency department hallway.

Where is anesthesia? This is exactly when you call anesthesia: A difficult airway in an unstable, obese patient who cannot lie flat. This is precisely what we’re trained for. And yet, no anesthesia provider is called or appears.

Why was he still intubated afterward? Once the imaging was complete, the patient is shown clearly breathing, communicating, and stable. If the goal was stabilization or to facilitate the procedure, anesthesia would typically extubate as soon as it’s safe to do so.

The whole sequence felt like the writers wanted to showcase a dramatic, high-stakes airway procedure without understanding when, why, or how it would actually be done—or who would actually be doing it.

Why Anesthesia Erasure Matters

Anesthesia providers exist. We manage difficult airways. We get called to the ER for situations exactly like this. And our absence from a show that prides itself on realism is a choice.

Just like the nursing erasure in Part 1, this sends a message about whose expertise matters, whose work is worth showing, and who gets credit for keeping patients safe.

Emergency medicine is a team effort. ER doctors, nurses, respiratory therapists, anesthesia providers, pharmacists—we all play a role. And when a show erases entire professions, it distorts what healthcare actually looks like.

I don’t expect The Pitt to be a documentary. But when the small details are right—the chaos, the team dynamics, the way people move through a trauma bay—the inaccuracies stand out even more.

And this one’s pretty glaring.

Next week: Back to regular anesthesia content. If there are topics you’ve been curious about—or things you’ve seen on TV that seemed off—let me know in the comments.

Subscribe for weekly posts breaking down what actually happens in anesthesia and the OR. New posts every Thursday. It’s free.

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