Awake in the operating room

Every year thousands of Americans prefer to undergo surgery without general anaesthesia


To her surgeon, all the hammering, sawing and drilling was just part of another hip replacement surgery. But to Sharon Leef, wide awake on the operating table at Cedars-Sinai Medical Center in Los Angeles several weeks ago, it was another life experience.

"I've climbed the pyramids in Egypt, and I just looked at this as part of life," said the 50-year-old flight attendant from Huntington Beach, California in the U.S.

"I learned a lot about the operating room and I got a chance to see my hip bone too."

Faced with such a gruelling procedure, one that would make those of us who aren't surgeons or morticians rather squeamish, many patients would prefer not to know the details, let alone watch the action taking place in real time. Not Leef, however, who asked that she be kept awake and alert through four hours of surgery while doctors extracted her worn-out left hip bone and replaced it with a new prosthetic one. She was, of course, anaesthetised in the area of the surgery, so she felt no pain.

Leef is one of the estimated tens of thousands of Americans who each year choose to undergo surgery without general anaesthesia that is, without being "put completely under," according to the American Society of Regional Anesthesia and Pain Medicine, or ASRA, a nonprofit group based in Richmond, Virginia. Like Leef, these patients are administered regional anaesthesia that blocks the pain in the surgical area while leaving them in various states of awareness during the procedure. With general anaesthesia, patients are unconscious during surgery and have no memory of the experience.

Several factors are driving the trend toward more patients forgoing general anaesthesia. For one, more people, especially baby boomers, want to participate more fully in their medical care. Improvements in medical technology, such as smaller needles and catheters, are also playing a role, as are the rise in less invasive surgeries and improvements in sedative drugs.

Also, regional anaesthesia allows patients to recover more rapidly, improves surgical outcomes and enables patients to be discharged earlier, cutting down on hospital bills.

Although the technology used in regional anaesthesia has been around for years the most common form, epidurals given to women during childbirth, dates to the early 1970s the technique has recently become an increasingly popular choice for patients undergoing increasingly common knee and shoulder repairs.

In a much smaller number of cases, regional anaesthesia has even been used in heart and brain surgery. As many as one in three patients undergoing an orthopaedic procedure now requests regional anaesthesia, according to ASRA figures.

"We've seen a dramatic increase in demand, especially within the last few years," said Dr. Terese Horlocker, president of the ASRA and professor of anaesthesiology at the Mayo Clinic in Rochester, Minnesota. "It's only going to go up."

To be sure, general anaesthesia is still preferred by most patients and their doctors especially for more complex surgeries. Typically, neck, chest and abdominal surgeries almost always require general anaesthesia.

But regional anaesthesia has a host of advantages over general. Regional anaesthesia is usually combined with a sedative to help the patient relax. That combination is used to place the patient in various stages of awareness, from fully awake and conversant to vaguely aware, with little or no memory of the surgery.

"The sedation is only for patient comfort," said Jonathan Hausman, an anaesthesiologist at Cedars-Sinai. "It's not needed for pain. The surgeon could easily operate with only a regional if the patient's nerves can handle it."

During surgery, general anaesthesia can cause a patient to aspirate and potentially choke. (Also, about one in 10,000 patients will die due to an adverse reaction to the anaesthesia, studies show.) With regional anaesthesia, there is no such risk of choking. However, in a small number of cases regional anaesthesia fails to deaden the nerves sufficiently to allow the surgeon to operate. In such cases, general anaesthesia is usually used.

General anaesthesia often has post-surgical side effects, including nausea, vomitting and prolonged mental fogginess, that regional anaesthesia doesn't have. Another advantage of the latter: Because the pain-numbing effects can sometimes last for several days after surgery, physical rehabilitation can start sooner, speeding recovery time.

Recent small studies suggest that in some cases heart bypass and intracranial angioplasties performed on patients who were still awake under regional anaesthesia faced fewer risks than those put under general.

In one study, doctors at the University of Pittsburgh reported that an awake patient's heart experiences significantly less stress during bypass surgery. In another, researchers at the Cleveland Clinic in Ohio found that monitoring a patient's neurological status during surgery helped guide surgeons thus, among other things, diminishing the likelihood of stroke.

"I was scared to death, but it wasn't bad," said James Houpt, 54, a Pittsburgh resident who became the first person in the Western Hemisphere three years ago to undergo heart bypass surgery under regional anaesthesia. "I remember saying, 'How you doing?' to the doctors and then I was in the twilight zone. I guess I tried to get up from the table and thank them after it was over, but I don't remember that."

Regional anaesthesia, however, does have some drawbacks. One is that it requires specialised training, which many anaesthesiologists do not have. Also, once injected, the anaesthesia can take up to 20 minutes to numb the patient. While many preparations for surgery are occurring simultaneously, the surgeon still must wait to be certain the pain block is working.

"There's definitely a perception that it takes more time," said Hausman, who attributes that perception to doctors being unfamiliar with the technique. But he adds that the delay is only for a few minutes.

And some surgeons opt not to recommend regional anaesthesia to patients out of concern that it will result in more distractions in the operating room. With the regional technique, doctors must give more thought to making the patient comfortable and reducing sources of anxiety, surgeons say. And they sometimes must contend with chatty patients, who may become bored during long procedures, peppering the surgical team with questions.

"With a patient awake or even sedated, you still have to be aware of things that would make a patient nervous or jumpy," said Dr. Lawrence Schecter, medical director at Santa Monica-UCLA Medical Center. "You have to pay attention to sounds in the room and what you say. It can be extra trouble."

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