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In surgery and awake

More patients are forgoing general anesthesia for medical and personal reasons.

June 02, 2003|Martin Miller | Times Staff Writer

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.

For The Record
Los Angeles Times Wednesday June 04, 2003 Home Edition Main News Part A Page 2 1 inches; 39 words Type of Material: Correction
Anesthesia -- An article in Monday's Health section on people who undergo surgery without general anesthesia incorrectly reported that Dr. Terese Horlocker is a surgeon at the Mayo Clinic in Rochester, Minn. She is a professor of anesthesiology there.
For The Record
Los Angeles Times Monday June 09, 2003 Home Edition Health Part F Page 8 Features Desk 1 inches; 37 words Type of Material: Correction
Anesthesia -- A story last week about people who undergo surgery without general anesthesia incorrectly reported that Dr. Terese Horlocker is a surgeon at the Mayo Clinic in Rochester, Minn. She is a professor of anesthesiology there.

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.

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