WHAT ARE THE CHALLENGES OF PERFORMING SURGERY ON AN AWAKE PATIENT?
The very first time that I attended a surgical procedure as a representative of a medical device company, I was completely shocked when the patient sat up in the middle of the surgery. He was awake, fully awake! Now that may not sound very exciting…but…this was a prostate treatment and I was standing in a prime location to view the procedure. My first thought was that the patient wouldn’t understand what I was doing looking at all of his business, but I relaxed when I realized that I was wearing scrubs and just looked like part of the team.
Procedures where a patient receives either no, light or conscious sedation are becoming more and more common for various clinical indications. There are distinct benefits including cost reduction and shorter recovery times for very specific procedures to be performed on awake patients. However, according to research published in the American Journal of Surgery by Smith et al (June 2017 Volume 213, Issue 6, Pages 996–1002.e1), awake surgery can add anxiety for patients as well as issues for the surgeon.
A few years ago, I was in an operating room to watch arthroscopic knee surgery where the patient had requested to be awake. It turns out that some people are fascinated and actually want to see their surgeon open up their knee. On second thought, maybe it is not so strange - we routinely have dental procedures done with only a local anesthetic.
During the surgery, the patient asked a lot of questions like - What is that beeping? What are you doing now? The orthopedic surgeon responded to each question while continuing to work on the patient’s knee. Afterwards, the surgeon shared that he prefers to have the patient fully asleep so that he doesn’t have to answer so many questions.
Not all procedures are suited to be performed as “awake surgery” even if a patient prefers local anesthesia or minimal sedation. This may be because of resultant pain or the need for the patient to lie completely still. An interesting fact is that brain surgery is not painful, as there are no pain receptors in the brain itself. This is one of the reasons that awake surgery in the brain is possible.
In brain surgery, awake surgery was pioneered decades ago in epilepsy patients. Keeping the patient alert was necessary so that surgeons could be sure of destroying the target tissue while not impacting vital brain tissue that controls motion, speech or other functions. Today, the ability to perform awake surgery with the patient providing feedback allows neurosurgeons to be extremely precise with their target.
The MR-guided focused ultrasound procedure for essential tremor is well-suited to be performed as an awake procedure. For the treatment team, patient physiological feedback allows fine tuning of the Vim target, while providing continuous evaluation of tremor improvement and close monitoring of any potential side effects. Focused ultrasound is quite unique in that the patient is part of the procedure, actually experiencing the improvement in their tremor during the treatment.
Having surgery is scary and being awake during surgery adds a whole new set of factors that can add to patient anxiety. To use the dental analogy again, the sounds of the drill and suction are familiar, but sometimes the fear of pain or the anticipation of what comes next grabs us as we lie with our mouths open.
For awake surgery, pre-operative communication with patients will better prepare them for the procedure and even the sounds, smells and cold temperatures to be expected in the operating room, while intra-operative communication (and maybe some great music) will continue to assuage their fears.
To this end, INSIGHTEC is currently preparing a downloadable application for neurologists and neurosurgeons to use to communicate with patients to prepare them for the MR-guided focused ultrasound procedure. The app uses simple animations to explain step-by-step what to expect before, during and after the procedure. The treating physician can set clear expectations for the patient about the procedure itself as well as about the outcomes.