My opinion

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There is always an ego which is the cooperative nuance evolving from the negotiation between the all-survivalist id and the all-altruist superego [1]. One of that ego is to choose the type of anesthesia. Now the question arises who chooses the type of anesthesia. Is it the patient? Is it the provider providing anesthesia? Is it the provider supervising the anesthesia? Is it the proceduralist who is performing the procedure? Is it the payer who is paying for anesthesia? Is it player who is socioeconomically regulating the practice of anesthesia? Or is it what that chooses the type of anesthesia? Is it the place or facility where the procedure is being performed? Is it the procedure itself? Or is it the phase of life in patient/provider/proceduralist, period of era among payer/player or even the time of the day in the facility where procedure is being performed?

The universal answer has been that procedure itself determines the type of anesthesia [2]. That is the ideal answer but procedure does NOT happen in a silo [3]. For certain procedures, there is only one option irrespective of what patient, anesthesia provider, anesthesiologist, proceduralist or facility environment wants. But, when there is no alternative to the one and only option for the feasible type of anesthesia, such procedures do not brew the egoistic conflicts while deciding the type of anesthesia. For all the remaining procedures, the types of anesthesia can be decided based on whatever patient wants, whatever anesthesia provider wants, whatever anesthesiologist wants, whatever proceduralist wants, and whatever facility environment wants. Herein, the egoistic conflicts arise especially when the reasons underlying the personal choices of anesthesia type do not come across clearly to the team because often those choices evolve over the time and the reasons being personal often getting buried in the subconscious of those making the choices are immediately inaccessible to the retrievable memory thus inexpressible in a professional voice by those making the choices.        

Sometimes we do not realize how many types of anesthesia there are to choose from. Following are just few examples of non-emergent elective choices:

• General endotracheal tube inhalational anesthesia with neuromuscular blocking drugs
• General endotracheal tube inhalational anesthesia without neuromuscular blocking drugs
• General endotracheal tube intravenous anesthesia with neuromuscular blocking drugs
• General endotracheal tube intravenous anesthesia without neuromuscular blocking drugs
• General supraglottic airway inhalational anesthesia with neuromuscular blocking drugs
• General supraglottic airway inhalational anesthesia without neuromuscular blocking drugs
• General supraglottic airway intravenous anesthesia with neuromuscular blocking drugs
• General supraglottic airway intravenous anesthesia without neuromuscular blocking drugs 
• General anesthesia mask inhalational anesthesia with neuromuscular blocking drugs
• General anesthesia mask inhalational anesthesia without neuromuscular blocking drugs
• General anesthesia mask intravenous anesthesia with neuromuscular blocking drugs
• General anesthesia mask intravenous anesthesia without neuromuscular blocking drugs 
• Spinal anesthesia with intravenous anesthesia without neuromuscular blocking drugs 
• Spinal anesthesia with anesthesia mask inhalational anesthesia without neuromuscular blocking drugs
• Epidural anesthesia with intravenous anesthesia without neuromuscular blocking drugs 
• Epidural anesthesia with anesthesia mask inhalational anesthesia without neuromuscular blocking drugs
• Combined spinal-epidural anesthesia with intravenous anesthesia without neuromuscular blocking drugs 
• Combined spinal-epidural anesthesia with anesthesia mask inhalational anesthesia without neuromuscular blocking drugs
• Regional plexus anesthesia with intravenous anesthesia without neuromuscular blocking drugs 
• Regional plexus anesthesia with anesthesia mask inhalational anesthesia without neuromuscular blocking drugs
• Peripheral nerve anesthesia with intravenous anesthesia without neuromuscular blocking drugs 
• Peripheral nerve anesthesia with anesthesia mask inhalational anesthesia without neuromuscular blocking drugs
• Local anesthesia with intravenous anesthesia without neuromuscular blocking drugs 
• Local anesthesia with anesthesia mask inhalational anesthesia without neuromuscular blocking drugs
• Intravenous anesthesia only 
• Spinal anesthesia only
• Epidural anesthesia only
• Combined spinal-epidural anesthesia only
• Regional plexus anesthesia only
• Peripheral nerve anesthesia only
• Local anesthesia only

The simple solution to avoid egoistic conflicts while choosing the type of anesthesia is just recollecting the reason for the choice, voicing that reason for the choice professionally, and negotiating within the team to finalize the agreeable choice for the type of anesthesia. No reason for the chosen type of anesthesia is unsavory as long as it neither undermines the safety nor exaggerates the overall cost exorbitantly. There may be reasons which may raise eyebrows and yet overrule any other reasoning for choosing the type of anesthesia.

• Patient's unshakeable fear against the safest type of anesthesia due to what they have heard about that type of anesthesia from others based on others' experiences.
• Anesthesia provider's or their supervising anesthesiologist's insufficient expertise in particular type of anesthesia precluding its use in the absence of alternate personnel availability.
• Multitasking proceduralist's schedule constraints denouncing certain types of anesthesia due to inherent delays therein during induction and emergence from such types of anesthesia.
• Payer's/Regulator's/Facility Administrator's guidelines precluding certain types of anesthesia especially if those types of anesthesia induced delays become unmanageably costly.

The bottom-line is that just like the choice of music genre being played in the procedure room [4], the choice of anesthesia type is a collaborative decision because a lot many procedures can be performed under a lot many anesthesia types and the egoistic conflict over the choice of anesthesia type should not disharmonize the musical environment inside the procedure room. Ultimately, it may be the time that has the final say in deciding the anesthesia type depending on which phase of life patient/provider/proceduralist is in, and/or which era payer/player has stakes in, and/or what time of the day it is when the procedure is being performed at a certain facility.   

Reference(s)

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1. Wired for Culture: Origins of the Human Social Mind. https://books.google.com/books?id=VjTeF2DRJvoC&pg=PT285&lpg=PT285&dq=mark+pag el+superego&source=bl&ots=AEcSFVSSO9&sig=ACfU3U0pUhs6XfJfQuh3oUKTJvxVYk90Eg&hl=en&am p;sa=X&ved=2ahUKEwjlk8Os7dXxAhUHG80KHQfIBZAQ6AEwBXoECA4QAw#v=onepage&q=mark%20pagel%20supere go&f=false
2. Procedure determines the type of anesthesia to be used. https://www.rgj.com/story/life/wellness/2018/09/05/procedure-determines-type-anesthesia- used/1205926002/
3. The Silo Mentality: How To Break Down The Barriers. https://www.forbes.com/sites/brentgleeson/2013/10/02/the-silo-mentality-how-to-break-down -the-barriers/
4. Music in the operating theatre - the great debate. https://healthcare-in-europe.com/en/news/music-in-the-operating-theatre-the-great-debate.html

Source(s) of Funding

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NOT APPLICABLE

Competing Interests

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NOT APPLICABLE