In surgery and awake

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 last week, it was another life experience.

“I’ve climbed the pyramids in Egypt, and I just looked at this as a part of life,” said the 50-year-old flight attendant from Huntington Beach. “I learned a lot about the operating room and I got a chance to see my hip bone too.”

Faced with such a grueling 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 brand-new prosthetic one. She was, of course, anesthetized 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 anesthesia -- 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, Va. Like Leef, these patients are administered regional anesthesia that blocks the pain in the surgical area while leaving them in various states of awareness during the procedure. With general anesthesia, patients are unconscious during surgery and have no memory of the experience.

Several factors are driving the trend toward more patients forgoing general anesthesia. 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 anesthesia 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 anesthesia 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 anesthesia has even been used in heart and brain surgery. As many as one in three patients undergoing an orthopedic procedure now requests regional anesthesia, 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 a surgeon at the Mayo Clinic in Rochester, Minn. “It’s only going to go up.”

Hospitals and medical schools are getting the message. Cedars-Sinai in Los Angeles, for example, recently recruited an anesthesiologist to help broaden its program in regional anesthesia, while Northwestern University in Evanston, Ill., is requiring all medical residents to get intensive training in regional anesthesia.

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

But regional anesthesia has a host of advantages over general. Regional anesthesia 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 anesthesiologist 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 anesthesia 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 anesthesia, studies show.) With regional anesthesia, there is no such risk of choking. However, in a small number of cases regional anesthesia fails to deaden the nerves sufficiently to allow the surgeon to operate. In such cases, general anesthesia is usually used.

General anesthesia often has post-surgical side effects, including nausea, vomiting and prolonged mental fogginess, that regional anesthesia 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 anesthesia 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 anesthesia. “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 anesthesia, however, does have some drawbacks. One is that it requires specialized training, which many anesthesiologists do not have. Also, once injected, the anesthesia 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 anesthesia 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.”

Patients such as Scott Markowitz of Los Angeles illustrate some of the challenges doctors face. The sixth-grade teaching assistant initially balked at the idea of being partially awake for his surgery last month to repair a torn rotator cuff in his arm. “At first, I told them no way. Just knock me out,” said Markowitz, 31. “I don’t want to know when they are cutting into my arm.”

For practical reasons, however, he later changed his mind. “I’m around kids all the time, and we have a graduation coming up,” said Markowitz. “So, if I can feel nothing during surgery and get back faster, I thought it would be a good idea.”

Before his recent 90-minute surgery, Markowitz had asked the doctors to keep him “half-awake,” and for the first minutes of the procedure he was. Then a problem arose when the 200-pound-plus man kept moving his free arm, distracting the surgeon. Eventually, the doctor requested that Markowitz be placed under heavier sedation.

After the surgery, because of the amnesic effect of his sedative, Markowitz remembered nothing.