November 03, 2026
Source/Image licensed from Ingram Image
Patients have all kinds of questions before receiving anesthesia. Among the most common: Why people can't drink coffee before surgical procedures.
You are lying on an operating room table. The lights are bright, the room feels cold, and someone is attaching monitors while another person checks your IV. You have met your surgeon. But now you have a few questions for the physician who is about to make you unconscious.
What if I wake up in the middle of surgery? Why did that medication burn going into my IV? What exactly is that milky white medication everyone talks about?
And perhaps most urgently, was skipping your morning coffee really necessary?
These are not silly questions. They get to the heart of what anesthesiologists actually do and what patients deserve to understand before a procedure.
Most people think our job begins when we put someone to sleep and ends when we wake them up. The truth is that some of our most important work happens in between.
Let's answer a few of the questions patients are often thinking but may be hesitant to ask.
Not every procedure requires being completely unconscious, and anesthesia is not a single medication or experience.
General anesthesia produces a controlled state of unconsciousness, typically using intravenous medications, inhaled anesthetics or a combination of both.
Sedation is different. It can range from feeling pleasantly relaxed and conversational to being deeply asleep and difficult to arouse. Under lighter sedation, you may hear voices, respond to questions or remember parts of the experience.
That doesn't necessarily mean something went wrong.
Regional anesthesia blocks sensation in a larger part of the body. For example, a spinal anesthetic may be used for certain lower-body operations while a nerve block can numb an arm or shoulder. Local anesthesia numbs a smaller area, such as the skin around a minor procedure.
The choice depends on the operation, your medical history, your comfort and, most importantly, your safety.
One thing I frequently explain to patients is that being "more asleep" isn't necessarily better. The safest anesthetic is the one best suited to the patient and the procedure.
This is one of the most common concerns patients have and understandably so.
The thought of becoming conscious while someone is operating on you sounds like the plot of a horror movie. Unfortunately, Hollywood hasn't done anesthesiologists any favors.
The reassuring news is that unexpected awareness during general anesthesia is rare. Estimates vary, but it occurs in approximately 1 or 2 of every 1,000 general anesthetics in some studies, depending on how awareness is defined and the patient population.
Even among patients who experience awareness, many report hearing sounds or recalling brief sensations rather than experiencing pain.
Nevertheless, awareness can be distressing, and preventing it is something we take seriously.
Throughout surgery, we continuously monitor vital signs, medication delivery and the patient's physiological responses. In selected cases, we also use specialized brain-function monitors to help assess the effects of anesthesia.
There is an important distinction between unexpected awareness under general anesthesia and remembering something during planned sedation.
If you're receiving moderate sedation and briefly hear someone speaking, that may be entirely consistent with the intended anesthetic.
If you have any concerns about awareness or a previous experience, tell your anesthesiologist before surgery.
Absolutely not.
I sometimes joke that patients have the easiest job in the operating room. They get to sleep through the entire procedure while everyone else works.
An anesthesia professional remains responsible for your care throughout the operation.
While the surgeon concentrates on the procedure, we are managing your breathing, circulation, medications, temperature and overall physiological stability.
Imagine a patient undergoing abdominal surgery. Shortly after anesthesia begins, the blood pressure drops. We may need to adjust medications, administer fluids or support circulation.
A change in surgical position affects the lungs, requiring an adjustment in ventilation.
Later, the patient's heart rate increases in response to surgical stimulation, prompting another change in the anesthetic.
These decisions happen constantly, often without the patient or anyone outside the operating room ever knowing.
Good anesthesia frequently looks uneventful, because we're working to prevent small problems from becoming major complications.
Our job doesn't stop when you fall asleep. In many ways, that's when it really begins.
Now we're getting to one of the most emotionally charged questions in anesthesiology.
For some patients, the thought of surgery is frightening. For others, being told they cannot have their morning coffee is apparently the greater medical emergency.
Imagine someone scheduled for surgery at 2 p.m. who has been told not to eat or drink anything after midnight. By 10 a.m., they're exhausted, irritable, thirsty and wondering whether the anesthesia team has declared war on caffeine.
Here's the good news: Modern fasting guidelines are often more flexible than patients realize. For many healthy adults undergoing elective procedures, the American Society of Anesthesiologists permits clear liquids until two hours before anesthesia.
That can include water, certain juices without pulp, clear tea and, yes, black coffee. The catch? Black means black. Once you add milk or cream, your coffee is no longer considered a standard clear liquid under these guidelines.
A light meal generally requires at least six hours of fasting, while heavier or fatty meals may require eight hours or longer.
Why do we care?
Because anesthesia can temporarily suppress the protective reflexes that normally keep stomach contents from entering the lungs.
If food or liquid travels from the stomach into the airway, a complication called pulmonary aspiration can occur. This can result in serious lung injury. Our fasting instructions are designed to reduce that risk.
However, the guidelines are not identical for every patient. Conditions that delay stomach emptying, certain medications and the type of procedure can all affect the plan. And hospitals may have specific protocols.
The bottom line: Follow the instructions provided by your anesthesia team, but don't be afraid to ask whether clear liquids are permitted.
I would much rather answer a question about morning coffee than discover that someone secretly ate a breakfast sandwich an hour before surgery.
Excellent question.
Imagine a patient involved in a serious motor vehicle accident. An hour earlier, they were enjoying a cheeseburger and fries. Now they're in the emergency department with injuries requiring immediate surgery.
We obviously cannot tell the trauma surgeon, "Sorry, we'll need to wait another seven hours for that cheeseburger to digest." Emergency surgery creates a different set of circumstances, and anesthesiologists are specially trained to manage them.
One technique we may use is called rapid sequence induction, or RSI. In a typical planned anesthetic, we have more flexibility in how we administer medications and establish the airway. In a patient at higher risk of aspiration, we may need to move much more quickly.
Rapid sequence induction involves preparing the patient and airway equipment, providing oxygen, administering medications that rapidly produce unconsciousness and muscle relaxation, and promptly placing a breathing tube into the windpipe.
The tube has an inflatable cuff that helps protect the airway and allows us to control ventilation. We also prepare suction equipment and other airway-management tools in case stomach contents are regurgitated.
The goal is to minimize the time during which the patient is unconscious without a protected airway. Does this eliminate the risk of aspiration entirely? No. But it is an important technique that can reduce risk when urgent surgery cannot wait.
Depending on the patient's injuries, condition and procedure, other airway and anesthetic approaches may be appropriate.
So while fasting guidelines are essential for elective surgery, emergencies require a different risk-benefit calculation.
And for anyone watching medical dramas such as "The Pitt," this is one of those moments when the real-life medicine can be every bit as intense as what you see on television.
The difference is that in an actual operating room, we're trying very hard to keep the drama to a minimum.
This is one of the fastest-evolving topics in anesthesia.
Medications such as Ozempic and Wegovy contain semaglutide, a drug that acts on the GLP-1 receptor. Other medications, including Mounjaro and Zepbound, use tirzepatide, which acts on both GIP and GLP-1 receptors. These medications are increasingly used to treat diabetes, obesity and certain related medical conditions.
But what does a medication for weight loss have to do with anesthesia? The answer is your stomach.
One of the ways these medications work is by slowing gastric emptying, meaning food can remain in the stomach longer than usual.
That may help patients feel full and eat less. However, it also can create an unexpected problem before surgery.
Imagine two patients who both stopped eating at midnight. One has normal gastric emptying. By the time surgery begins, the stomach is likely to have emptied appropriately. The other recently started a GLP-1 medication, is increasing the dose, and has been experiencing nausea and bloating.
Despite following the same fasting instructions, the second patient may still have food remaining in the stomach. Under general anesthesia or deep sedation, retained stomach contents may increase the risk of aspiration.
This concern initially led to recommendations that patients stop weekly GLP-1 medications at least seven days before elective procedures. However, the recommendations have evolved.
Updated multisociety guidance indicates that many patients can safely continue these medications before surgery, provided they are not at increased risk of delayed gastric emptying.
Patients who are just starting treatment, increasing their dose, experiencing significant gastrointestinal symptoms or taking higher doses may require additional precautions.
These can include a liquid diet for 24 hours before the procedure, adjustments to the anesthesia plan or, in selected circumstances, delaying an elective operation. Some anesthesia teams also may use bedside ultrasound to assess whether the stomach contains significant residual contents.
Importantly, stopping a weekly medication for seven days does not guarantee that gastric emptying has returned to normal. The decision needs to be individualized. Some hospitals continue to use more conservative protocols, so it's essential to follow the instructions from your own surgical and anesthesia team.
Most importantly, don't stop these medications on your own without discussing the plan with your prescribing clinician.
The lesson is simple: Tell your anesthesiologist about every medication you're taking, including medications prescribed for weight loss.
Your stomach may be telling us a very different story from your watch.
Ah, yes. The famous milky white medication that seems to have developed its own celebrity following. It's called propofol.
Propofol is one of the most commonly used intravenous anesthetic medications. It has a distinctive white appearance, because it is formulated as an emulsion containing tiny droplets of fat suspended in liquid. Hence its rather memorable nickname: "milk of amnesia."
Propofol works rapidly, and its effects can wear off relatively quickly after administration is stopped, making it useful for many forms of anesthesia and procedural sedation.
Patients frequently tell me, "One second you were talking to me, and the next thing I remember, I was waking up." That's the intended effect. But propofol is not an ordinary sleeping medication.
It can suppress breathing, lower blood pressure and produce profound unconsciousness. It must be administered by appropriately trained professionals with the monitoring and equipment needed to manage those effects.
And while it produces unconsciousness and amnesia, it is not itself a reliable painkiller. During surgery, we often combine different medications to achieve the appropriate balance of unconsciousness, pain control and physiological stability.
There's actually an entire fascinating discussion to be had about the medications we use during anesthesia, from propofol and midazolam to opioids, inhaled anesthetics and muscle relaxants.
That may deserve an article of its own.
That burning sensation when medication enters your IV is real. Certain medications, including propofol, can irritate the lining of a vein, particularly when administered through a small vein in the hand.
Depending on the situation, we can use medications or techniques to reduce that discomfort.
Then there's the mysterious metallic or chemical taste some patients experience after receiving IV medications or even a saline flush.
Patients sometimes ask, "How can I taste something that went into my arm?" It sounds strange, but there's a physiological explanation.
Substances entering the bloodstream can influence taste and smell, including through compounds that circulate to the lungs and are subsequently exhaled. Because much of what we perceive as taste is closely linked to smell, a medication introduced into the bloodstream may produce a temporary taste sensation.
And that peculiar smell from an anesthesia mask? Certain inhaled medications and the equipment used to deliver them can produce unfamiliar odors. Rest assured, we haven't accidentally switched the anesthesia machine to a new fragrance setting.
Your cannabis use. Your last alcoholic drink. Your prescription pain medications. The sleeping medication you took the night before. Your nicotine use, supplements or medications borrowed from someone else. And yes, even that edible you had over the weekend.
We're not asking these questions because we're interested in judging your personal choices. We're asking because these substances can significantly influence how your body responds to anesthesia.
Regular cannabis use may alter anesthetic requirements and recovery. Opioids and benzodiazepines can interact with sedating medications and increase the risk of respiratory depression. Heavy alcohol use can affect anesthetic needs and create withdrawal concerns. Even seemingly harmless supplements can have implications for surgery.
I often tell patients that there are very few answers they can give me that will surprise me. What concerns me is the information I don't have.
Anesthesiologists can usually develop a safe plan around the truth. We cannot reliably plan around a carefully edited version of your medical history.
This is another surprisingly common concern. Fortunately, anesthesia is not a truth serum.
As medications wear off, patients may become talkative, emotional, confused or unusually enthusiastic about things they would otherwise never mention.
Some patients wake up and immediately ask whether the operation is about to begin. Others repeatedly ask the same question despite receiving the answer approximately 30 seconds earlier. One of the more familiar recovery-room exchanges goes something like this:
"Doctor, when are we starting?"
"We're finished. Everything went well."
"Really? Are you sure?"
"Yes, I'm quite sure."
While patients can occasionally say amusing things during recovery, confused statements made while emerging from anesthesia are not reliable confessions.
And no, we're not collecting material for a reality television series.
Our priority is making sure patients are breathing comfortably, recovering safely and receiving appropriate treatment for pain and nausea.
The recovery room is a place for medical care, not interrogation.
A physician anesthesiologist is a medical doctor who completes medical school and specialized residency training in anesthesiology. Some complete additional fellowship training in areas such as cardiac anesthesia, pediatric anesthesia, critical care or pain medicine.
A certified registered nurse anesthetist, or CRNA, is an advanced practice registered nurse who has critical-care nursing experience and completes specialized graduate-level nurse anesthesia education and certification.
CRNAs play an important role in anesthesia care, and their practice arrangements vary according to state law and the clinical setting.
In many hospitals, physician anesthesiologists and CRNAs work collaboratively as part of an anesthesia care team.
The important thing for patients is to understand who is responsible for their anesthetic care, what type of anesthesia they will receive, and who they should speak with if they have concerns.
Anesthesiology is a remarkable combination of medicine, physiology, pharmacology, critical care and split-second decision-making.
It requires us to understand how nearly every organ system responds under stress and to anticipate problems before they become emergencies.
Unlike many medical specialties, we often meet our patients only minutes before they place an extraordinary amount of trust in us. Then we spend the next several hours helping protect their lives while they remain completely unaware of the work being performed on their behalf.
There may not be much glamour in that.
Patients rarely remember the medications we administered, the airway decisions we made or the changes in blood pressure we corrected. But that's perfectly fine with me.
One of the greatest compliments an anesthesiologist can receive is a patient waking up comfortably and saying, "That was it? I don't remember a thing."
The success of anesthesia is often measured by what never happens: an airway complication prevented, a dangerous change in blood pressure corrected early, or a patient who awakens safely and comfortably.
And for the patient who is still worried about that forbidden morning coffee? My advice is simple: Ask your anesthesia team about the current fasting guidelines before resigning yourself to an entire morning without caffeine.
We may be responsible for putting you to sleep, but that doesn't mean we want you miserable while you're awake.
So when someone asks, "What does the anesthesiologist actually do after I fall asleep?" my answer is straightforward:
We don't stop working when you stop remembering.
That's when some of our most important work begins.
Michael Sabia, M.D., is professor of anesthesiology at Cooper Medical School of Rowan University, division head of Pain Management, and medical director of the Integrated Pain Program at Cooper University Health Care. His work focuses on anesthesiology, interventional pain management and improving access to safe, evidence-based care.
