AAMGI provides acute and chronic pain management services in hospitals, clinics, and surgery centers throughout the northern San Francisco Bay Area.

Acute Pain Management

Acute pain is the normal, predicted physiologic reaction associated with surgery or procedure. Your anesthesiologist will use the best technique and option, and frequently, a combination of techniques and options, for treating pain associated with your surgery or procedure both during and immediately after the procedure. These techniques and options may include general anesthesia, regional blocks, sedation and/or oral medication.

Ambulatory Anesthesia

When you do not need to stay overnight in the hospital after a procedure or diagnostic test, the surgery is referred to as ambulatory surgery or outpatient surgery. Ambulatory anesthesia is designed to meet the needs of ambulatory surgery, so that you may go home soon after your operation. Specialized anesthesia techniques and short-acting anesthesia drugs combine to make the experience safe and pleasant.If you are in generally good health, ambulatory surgery may be a cost effective, convenient option for you. Your anesthesiologist will carefully evaluate your health and history to determine if ambulatory anesthesia is right for you. He or she will interview you to gather information, either by phone or during your visit to the facility. You may be asked to undergo laboratory tests, and provide information about allergies and other medical conditions. Feel free to discuss questions and concerns with your anesthesiologist at this time.

Anesthesia for Total Knee Replacement

Our anesthesiologists use anesthesia techniques described below which have been developed and specifically tailored for a total knee replacement. Our goal is to provide you with a safe and comfortable experience. We tailor the anesthesia specifically for you. In general, your anesthesia for this surgical procedure will likely consist of three main parts:

  1. Regional Anesthesia – please see our section on regional anesthesia for more details. With very few exceptions, we and your surgeon both recommend some form of regional anesthesia. Your anesthesiologist will discuss the details with you before your surgery, but typically the regional anesthesia procedure will take place prior to your entering the operating room. Depending on your surgeon, your anesthesiologist, and you, the regional technique will either consist of a single injection of numbing medication, or placement of a nerve catheter. The goal of the regional anesthesia is to maximize your comfort, and minimize your pain both during and after the procedure.
  2. Once the regional anesthesia has been placed, you will be brought back to the operating room where your anesthesiologists may offer you some relaxation medication in preparation for the spinal anesthesia. The spinal anesthesia involves using a hair-sized needle to provide a single injection of numbing medication to your lower back, which will numb both of your legs. This allows for further comfort and further reduction in pain both during and after your procedure. Because your body is now comfortable, the amount of anesthesia that your anesthesiologist will use to keep you relaxed is significantly less. This usually results in less of the bothersome side effects commonly associated with anesthesia, such as nausea, drowsiness, and lethargy.
  3. Most people prefer to sleep during the procedure, and your anesthesiologist can give you medications to help you stay comfortable. Many people describe pleasant dreams from this part of the anesthesia.

Your anesthesiologist will remain with you for the duration of your procedure. Following the procedure, your anesthesiologist will accompany you to the recovery area, where you will be monitored closely. This is the period where you will continue to awaken, and hopefully the tailored anesthesia has left you pain free and nausea free, but we will be there to address any pain or nausea you may have.

If you’ve had a nerve catheter placed, your anesthesiologist will prescribe the appropriate medication to be delivered over the next couple of days to help minimize your discomfort.


Within AAMGI we have a team of anesthesiologists dedicated to the preoperative, intraoperative, and postoperative care of patients undergoing heart surgery. These individuals have specialized training including fellowships, certifications and continuing education in advanced manipulations of physiology, applications of pharmacology, resuscitative techniques and advanced monitoring in cardiac anesthesia. They work closely with the cardiac surgeons and cardiologists to provide anesthesia for all types of cardiac procedures including minimally invasive cardiac surgery, thoracic aortic surgery, bypass surgery and complicated electrophysiologic cardiology procedures.

Continuous Peripheral Nerve Blocks (CPNB)

Continuous peripheral nerve block (CPNB) techniques provide analgesia for a specific target location during a variety of surgeries. Unlike a single-injection, a CPNB involves inserting an indwelling catheter in the area of a target nerve. This allows for a continuous stream of local anesthesia to be infused through the catheter to the nerve, providing numbness. CPNB, a type of regional anesthesia, uses this continuous catheter to also provide pain relief over an extended period of time.

By using CPNB for many types of surgeries involving arms and legs, patients are often able to have same-day discharges, whereas without it an overnight stay in the hospital would be necessary to monitor pain.

Your anesthesiologist will determine if CPNB is right for you.

Geriatric Anesthesia

As people age, their cardiac, respiratory and renal physiology naturally begins to change. This can make it more difficult to determine how the patient will respond to surgical stress. Elderly patients are also more likely to have conditions or diseases that must be closely monitored during surgery and when administering anesthesia. For these reasons, prior to surgery your anesthesiologist will carry out a complex and extensive preoperative evaluation. During this time, you will be asked many questions about your health history, and may undergo routine tests to help your anesthesiologist determine the best method for you.

Please discuss any concerns you may have with your anesthesiologist or surgeon.

GI Anesthesia

The importance and usefulness of early detection in the prevention of colon cancer has made colonoscopy commonplace in modern medicine. The development of newer powerful anesthetics that can be administered by an anesthesiologist enable these procedures to be essentially painless. Because these powerful medicines are both quick to work and quick to wear off, patients no longer have the lingering sedative effects of the older medicines that lasted long after the procedure was over. Patient safety is optimized by the anesthesiologist’s undivided attention to the patients’ vital signs, and the gastroenterologist benefits from the improved environment provided by a quiet and comfortable patient. Also commonplace today are upper endoscopic procedures that involve examination of the esophagus, stomach and duodenum. This procedure is also painless and safe when performed with the newer medicines administered by an anesthesiologist.


All the physician anesthesiologists at AAMGI are here to provide expert care during your delivery. We know this time can be filled with a lot of questions & uncertainties especially when it comes to your anesthesia options. You will be provided 24 hour care from an anesthesiologist dedicated to the obstetrical floor. Pain relief options during labor include opioid pain medication that is given through your IV and regional anesthesia that is performed by an anesthesiologist. We will first review your medical history and take the time to answer any questions you may have prior to the procedure.

Every woman experiences pain differently, especially during childbirth. There are many factors that contribute to the amount of pain you will feel during labor. The size and position of the baby, as well as the strength of the contractions will all factor in to your experience. In some cases, women find relief in relaxing and breathing techniques learned in classes prior to childbirth. Other women may opt to use these techniques along with pain medications.

Analgesics and anesthetics are the two types of pain-relieving drugs used for women during childbirth. There are many types of analgesics and anesthesia, and each are used for the different needs of each individual woman. Your AAMGI anesthesiologist will help you determine which type of pain relief is right for you.

Local Anesthesia

Local anesthesia provides loss of sensation in small area. It does not lessen the pain from contractions. Sometimes, your obstetrician will perform a procedure called an episiotomy prior to or during labor. Local anesthesia is often used during an episiotomy, or when vaginal tears occur during childbirth. Local anesthesia rarely affects the baby, and there are generally no side effects after the numbing wears off.

Regional Analgesia

Regional analgesia is generally the most effective pain reliever, with the fewest side effects. Epidural analgesia, spinal blocks, and combined spinal-epidural blocks are the three types of regional analgesia used to minimize labor pain.

Epidural Analgesia: Epidural analgesia, or epidural block, causes loss of sensation in the lower region of your body, yet leaves you fully conscious and alert. It can be given right after contractions start, or later in your labor. Sometimes, an epidural analgesia is used in combination with other anesthesia during a cesarean delivery.

An epidural block should make you more comfortable, though you may still be aware of your contractions and feel your doctor’s exams as labor progresses. There is a small risk of medication being injected into one of the veins surrounding the epidural space, and if this occurs you may feel dizziness, rapid heartbeat, numbness or a funny taste in the mouth. Tell your doctor right away if this occurs. Regional anesthesia for labor is a continuous epidural which is placed by an anesthesiologist in your lower back. An epidural is simply a small & soft catheter that is placed between the bones in your lower back to help ease the pain you feel during contractions through the use of local anesthesia. Once the epidural is placed, a pump will continuously run a safe amount of local anesthetic during your entire labor process to ensure you have pain relief during delivery. After an epidural is placed you will still be able to move your legs and will be able to participate in pushing during delivery. If for any reason you need to have a cesarean section during your labor process we can infuse stronger local anesthesia into the epidural to make you ready for surgery. For those patients with a scheduled cesarean section, we provide spinal anesthesia to prepare you for surgery. With a spinal anesthetic, you will be numb from your chest down and will be awake for the birth of your baby.

Spinal Block

A spinal block is also injected in the lower back. It uses a much smaller dose of the drug than an epidural block, and is injected into the sac of spinal fluid below the level of the spinal cord. Pain relief is immediate in the lower half of the body, but the effects only last an hour or two.

A spinal block is used only once during labor, often when the baby needs help out of the birth canal with forceps or by vacuum extraction. Like an epidural block it can be used with stronger anesthesia for a cesarean delivery, and has the same side effects as an epidural block. Again, if these occur, tell you doctor right away.

Combined Spinal-Epidural Block: A combined spinal-epidural block is just what it sounds like. It combines both methods of pain relief, thereby giving you the fast relief of a spinal block, along with the extended pain relief through delivery of an epidural block.

Systemic Analgesics

Systemic analgesics are given as injections into a muscle or vein. They lessen pain, while you remain conscious, and act on the whole nervous system rather than one specific area. Systemic analgesics are not given right before childbirth, as they may slow the baby’s reflexes and breathing at birth.

General Anesthesia

General anesthetics are medications that cause you to lose consciousness and go to sleep immediately after injection. You will feel no pain and not remember the experience when you wake up. General anesthesia is usually used when an emergency cesarean delivery is needed and there is insufficient time to allow for a spinal anesthetic.

A major risk of general anesthesia is caused when a woman has food or liquids in her stomach. During labor, undigested food stays in the stomach. While unconscious, this food may come back up and go into the lungs, causing damage. Therefore, you may be asked to not eat or drink once labor has started. You will need an antacid to reduce stomach acid, and a breathing tube will be inserted after you are asleep.

Depending on what is best for the health of you and your baby you may be given spinal, epidural, or general anesthesia for a cesarean delivery.

Pediatric Care

If your child needs an operation requiring anesthesia, your anesthesiologist will do everything possible to ensure that your child remains safe and comfortable. He or she will constantly be regulating your child’s breathing, heart action, and blood pressure, and closely monitoring for other unexpected complications that may rarely occur during surgery.

An anesthesiologist my also be present in other types of hospital visits, such as during a specialized radiological test including diagnostic scans. Anesthesiologists may also be present to provide pain relief for your child, and consulted in the pediatric intensive care unit.

How can I help as a parent?

The anesthesiologist and surgeon will do everything they can to make your child’s experience as pain-free and positive as possible. However, as a parent, your role in the process is extremely important. Children feel much safer in surgery when they are well prepared, so it is important you talk to them about what to expect as much as possible. It is important to be honest with your child, explaining that he or she will be in an unfamiliar environment, and that there may be some discomfort after the operation. Remind your child that even though you cannot be there the entire time, he or she will be well taken care of by many doctors and nurses, and that you will be waiting nearby.

On the day of the operation, it is expected that you and your child will be nervous. Try not to show your anxiety, but rather reassure your child that everything the doctors do will be explained beforehand, and that they are trustworthy and there to help. Your confidence and composure can greatly affect your child’s experience and will help ensure that everything goes smoothly.

What will the anesthesiologist need to know?

During your pre-surgery consultation, the anesthesiologist will need to make sure your child is in the best possible physical condition for the operation. He or she will need to know your child’s and family’s complete medical history, especially whether anyone in the family has had complications from anesthesia. If your child has a cold or other minor illness, your anesthesiologist may decide to postpone surgery, as it can pose a risk to the effectiveness and safety of anesthesia.

During the consultation, you and your child will also have the opportunity to ask any questions or address concerns with your anesthesiologist.

Will my child receive any medication before surgery?

In the past, every child was given a sedative before surgery, However, doctors now agree that many children do not require sedation if they remain calm, and have a confident reassuring parent to help them through the stress of an operation. Some children may still need a sedative despite how calm their parent remains. In this case, the medication will be given by mouth, injection, or rectal suppository. The time this medication will be administered varies, and the anesthesiologist will determine the type of medication given.

How will my child be given anesthesia?

Anesthesia can be administered in several different ways. Usually with adults, anesthesia is injected so that the patient becomes unconscious rapidly. This method can also be used on children. Another option for children is breathing anesthetic agents, so that unconsciousness comes gradually. In this method, your child will be asked to breathe quietly though a “space mask,” and no needles will be necessary until after he or she is asleep. Your anesthesiologist will decide which method is best for your child.

Regional anesthesia may be another option for your child. With regional anesthesia, one part of the body can become numb so that surgery can be performed. For example, if your child was having foot surgery, a local injection of an anesthetic can eliminate pain and require less general anesthesia. Epidural anesthesia is often used on children, similar to that used for childbirth. Regional anesthesia can also be used for pain relief after surgery. Your anesthesiologist will discuss the advantage and disadvantages of different types of anesthesia with you.

Anesthesia does occasionally have side effects. It tends to decrease breathing, heart action, and blood pressure. Your anesthesiologist will monitor these effects carefully. Children awaken from anesthesia at different rates. Some may be fully awake after surgery, and others may take several hours before they are fully alert. Nausea and vomiting are common side effects following anesthesia. If you have any concerns about your child’s recovery, feel free to discuss them with your anesthesiologist.

How is pain controlled after surgery?

Your anesthesiologist may be consulted in helping manage your child’s pain after surgery. Some forms of pain relief your anesthesiologist may recommend include intravenous or oral medications and occasionally a nerve block may have been placed to ensure that the surgical site is numb after surgery.

Peripheral Nerve Blocks and Peripheral Nerve Catheters

Our goal is to help you through your operation safely and comfortably. Along with IV and oral medications for post-operative pain, there are various techniques used to numb the surgical area for a few hours to days after the operation. Our Anesthesiologists are specifically trained and highly experienced in using the latest ultrasound-guided techniques for safe placement of numbing medicine to relieve post-operative pain. Using an ultrasound machine to visualize the nerve to the surgical area, a local anesthetic (numbing medicine) is injected around the visualized nerve. This can last for up to 16-20 hours after the operation. If necessary, for longer lasting post-operative pain control, we can insert a small catheter (small tubing) into the area near the nerve beneath the skin that remains in place for a few days after the surgery. Through this small tube, local anesthetic (numbing medicine) is slowly injected providing numbing to the surgical area. This can greatly reduce the amount of pain felt post-operatively and, in combination with oral pain medication, greatly enhance recovery from your operation or procedure.

Transesophageal Echocardiology (TEE)

TEE is a test performed to evaluate the overall health of your heart’s valves and chambers, determine the presence of many types of heart disease, and/or assess the effectiveness of valve surgery. Similar to an echocardiogram, which produces a graphic outline of the heart’s movement using high-frequency sound waves, a transesophageal echocardiogram provides a closer look at the heart’s valves without interference from the lungs or ribs. TEE is performed when a standard echo test is not sufficient, or your doctor needs a closer look at your heart.

How is a TEE performed?

First, several electrodes, or flat sticky patches, are placed on your chest. These patches are attached to the echocardiogram monitor (EKG) that monitors your heart’s electrical activity. A blood pressure cuff and a small clip connected to a pulse oximeter is attached to your arm and finger to monitor your blood pressure and the oxygen level in your blood. Your throat will then be numbed with an anesthetic spray, or a pain relieving medication that will allow for a painless procedure. Then, sedatives will be administered through an IV by your anesthesiologist. You will begin to feel drowsy at this point. Next, a thin endoscope will be placed in your mouth and down your throat to the esophagus. You may be asked to swallow, to help guide the endoscope down. This part of the procedure may be uncomfortable, but it will not interfere with your breathing. Once the probe is in place, it takes images of the heart at various angles. As with all similar procedures, your anesthesiologist will be monitoring your blood pressure, breathing and oxygen level in your blood.

Can I eat or drink the day of the test?

You may not eat or drink anything for at least 6 hours prior to the test, as doing so may complicate the test or the sedation. Water may be permitted up to about 2 hours before the test. Your doctor will go over these instructions with you.

Is the process painful?

Because you will be sedated, you will not be fully aware during the test, and will be numbed, therefore feeling no pain. Your anesthesiologist will keep you as comfortable as possible throughout the process.

How long does the TEE procedure take?

The entire process should take about 90 minutes. After you have recovered from the sedative you receive, you will be free to go home. However, you WILL need someone to drive you home following the test, as you will have been sedated and not ready to operate machinery.

Is TEE safe?

TEE is a relatively common and generally safe procedure. However, as with many diagnostic tests and procedures, complications or side effects may occur. In rare cases, patients may experience breathing problems, abnormal heart rate, minor bleeding, or reactions to the sedative. More commonly, your throat may feel temporarily sore or numb following the test, due to the presence of the transducer in your throat. Your doctor and anesthesiologist will discuss the risks and benefits with you prior to operating.

How soon will I get the results?

Your doctor will have the results immediately following the test. However, he or she may want to review it before your consultation to discuss the results. You may also be drowsy from the sedation following the procedure, and not ready to be explained the final report. A conference will be set up for a later date.

Trauma Care Anesthesia

Trauma services involve care for patients with acute injuries, both large and small, on an emergency basis. These injuries can result from a fall, accident or a fight and include stab wounds, gunshot wounds, injuries to organs, major orthopedic injuries to bones, spinal injuries and vascular injuries. Physicians undergo specialized training for treating trauma patients. Our anesthesiologists provide trauma anesthesia services to patients who come to the hospital on an emergency basis with a trauma injury. Trauma anesthesia requires specialized care for introducing lines to administer fluids and complex airway management in the administration of anesthesia services.

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