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Alternatives to General Anesthesia

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It’s becoming more common—even for fairly complex operations. Instead of general anesthesia, which makes you unaware and immobile during surgery, you stay awake.

Why it’s happening: “Regional -anesthesia,” such as nerve blocks and epidurals, are now more accurate, effective and safe.

Why it’s a good thing: Recovery time is generally faster, with fewer side effects, so you get to go home sooner. There may be less post-operative pain as well, which can reduce the need for opioids during recovery. Here’s why: Regional anesthesia blocks painful stimuli completely. So you wake up in less pain and need less acute pain relief. Bonus: Costs are lower, too.

THE DOWNSIDES OF GOING UNDER

Let’s be clear—overall, general anesthesia is safe and getting safer. Fewer than one in 100,000 US surgical patients die from general anesthesia. But many patients wake up with side effects, such as nausea, vomiting and sore throats (from the breathing tubes). An unlucky few suffer breathing problems that can lead to infections, even pneumonia. Plus, studies show that many patients feel less anxiety if they can remain at least partially awake during surgery.

ALTERNATIVES TO GOING UNDER

The primary forms of regional anesthesia are…

• Nerve block. A local anesthetic medication is injected near nerves that affect specific body parts. Anesthesiologists use ultrasound to guide the needle to exactly where it will reach the right nerves.

• Spinal anesthesia. Anesthetic medicine is injected into spinal fluid inside the lower back, quickly numbing the lower half of the body.

• Epidural. Anesthetic medicine is injected outside the spinal fluid sac. It takes longer to work, but a tube can be left in place to give you pain relief after the operation.

• Sedative. Since the regional anesthetics will not affect the central nervous system—meaning you’ll stay awake—you’ll be offered a sedative drug to relax you and ease anxiety.

SURGERY WITHOUT GOING UNDER

So can you just say, “No thanks, doctor”? Not always. Example: In nearly all cases, open-heart and other chest surgeries require general anesthesia. So do nearly all abdominal and brain operations.

But a growing list of surgeries can now be performed without general anesthesia if you and your doctors agree. Here are several common ones…

JOINT REPLACEMENT

Nerve blocks, which work very well for individual body parts such as legs and arms, can be ideal for joint replacement. For hip or knee replacement, a spinal or an epidural may be used instead.

ACL RECONSTRUCTION

Anterior cruciate ligament (ACL) reconstruction is similar to joint replacement and can now be done with various regional anesthesia techniques. These options are often preferred by the generally younger, fitter patients who frequently require this surgery.

PROSTATE SURGERY

Spinal or epidural anesthesia can be ideal for these surgeries. If the surgery is for cancer, you are likely to need heavy sedation as well because such procedures can be extensive. Less sedation may be needed for transurethral resection of the prostate (TURP), a technique used to reduce an enlarged prostate gland.

FACE-LIFT

Here, your choice of anesthesia will most likely be guided by your choice of plastic surgeon. Some prefer an alert patient who can make facial expressions during the procedure, so they offer patients nerve-blocking injections along with light sedation. Others feel they can do better work with unconscious patients. If you have your own preference, choose your surgeon accordingly.

THE RISKS OF REGIONAL ANESTHESIA

While safer overall than general anesthesia, regional techniques do have some risks…

• Sedatives: Drugs such as propofol, fentanyl, midazolam and ketamine are generally safe when used during surgery but can leave you woozy and muddleheaded for a while afterward. Make sure you have someone to drive you home.

• Nerve blocks: Nerve injuries are very rare but can occur. Overdoses and misplaced needles can allow drugs to get into the bloodstream, which might cause confusion and even seizures.

• Spinal and epidural anesthesia: Risks include nerve injury, infection, bleeding and headache. These are rare.

To lower your risks: Thoroughly and honestly answer all the questions your anesthesiologist will ask about your medical history. But also ask questions. Not all anesthesiologists are trained in using ultrasound to guide a nerve block, for instance. Ask about your surgical team’s experience with using these regional techniques for your specific surgery.

What if you still want general anesthesia? That’s not uncommon or wrong. The idea of being even partially aware during surgery makes some people extremely anxious. Others are poor candidates for regional anesthesia because of medical problems. But if it’s right for you, you’ll likely recover faster and get home sooner.

HOW AWAKE DO YOU WANT TO BE?

If you choose regional anesthesia for surgery, you also may face a second choice—just how sedated do you want to be?

Some people want to remain awake and fairly aware…others want the oblivion of “twilight sleep.” The less sedated you are, the more you’ll be aware of your surgical team talking, as well as sensations such as tugging and pressure (though not pain). It’s a good topic to discuss with your doctor.

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Source: David Sherer, MD, a board-certified anesthesiologist who is president and CEO of Consolidated Medicine, a medical practice and consulting group in Chevy Chase, Maryland. He is coauthor of Dr. David Sherer’s Hospital Survival Guide: 100+ Ways to Make Your Hospital Stay Safe and Comfortable. His blog on BottomLineInc.com is titled “What Your Doctor Isn’t Telling You.”
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