Awake, alert and un­der the knife

Con­scious se­da­tion be­com­ing more com­mon for cer­tain sur­gi­cal pro­ce­dures as re­search finds it im­prove out­comes and low­ers costs.

The Star Malaysia - Star2 - - HEALTH - By JEREMY OLSON

THE re­place­ment of Roy Noth­nagel’s de­fec­tive heart valve had reached a key point; si­lence filled the op­er­at­ing room at Ab­bott North­west­ern Hos­pi­tal as Dr Paul So­ra­jja and his team pre­pared to im­plant a new valve – and re­act if their pa­tient fal­tered.

Then came the wise­crack. “God,” a bari­tone voice said, “I feel like I’m in Hous­ton and there’s a rocket launch.” It was Noth­nagel. Un­til re­cently, pa­tients in his place would have been un­con­scious by this point. But now, Ab­bott and other hospi­tals are keep­ing them awake as part of a broader ef­fort to limit the use of gen­eral anaes­the­sia due to grow­ing ev­i­dence that it can hin­der a pa­tient’s re­cov­ery and leave long- term ef­fects on the body.

Re­search also sug­gests that min­i­mal, or con­scious, se­da­tion dur­ing valve im­plants im­proves out­comes and short­ens hos­pi­tal stays.

And, oc­ca­sion­ally, it gen­er­ates comic re­lief in the OR.

“It used to take weeks in the hos­pi­tal to re­cover from this pro­ce­dure,” So­ra­jja said. “Now it is es­sen­tially be­com­ing an out­pa­tient pro­ce­dure.”

Ab­bott joined a grow­ing list of hospi­tals this month when it started us­ing con­scious se­da­tion for tran­scatheter aor­tic valve re­place­ments, or TAVRs, which in­volve thread­ing a re­place­ment valve in­side an artery so it can reg­u­late blood flow out of the heart. The Univer­sity of Min­nesota Med­i­cal Cen­ter also prefers con­scious se­da­tion for the pro­ce­dure.

Gen­eral anaes­the­sia re­mains crit­i­cal for many life­sav­ing surg­eries, but stud­ies are show­ing that it can re­sult in health prob­lems, said Dr J. P. Aben­stein, a Mayo Clinic physi­cian and past pres­i­dent of the Amer­i­can So­ci­ety of Anes­the­si­ol­o­gists.

“When I was in train­ing in the 80s, if pa­tients were alive and kick­ing 24 hours af­ter ( pro­ce­dures) then anaes­the­sia was off the hook,” he said.

“To­day, we re­alise there is long- term con­se­quence to the heart, to the kid­ney, to the brain.”

It doesn’t al­ways work: Aben­stein said most doc­tors switched back to gen­eral anaes­the­sia for cer­tain gas­troin­testi­nal pro­ce­dures be­cause it was bet­ter for pa­tients.

And even with TAVRs, one in 10 pa­tients re­ceiv­ing con­scious se­da­tion in the US are switched to gen­eral anaes­the­sia be­cause they can’t sit still or com­pli­ca­tions oc­cur.

“That is the down­side,” said Dr Ganesh Raveen­dran, an in­ter­ven­tional car­di­ol­o­gist at the Univer­sity of Min­nesota. “If there is a disas­ter or an emer­gent need, then there would be an emer­gency in­tu­ba­tion and place­ment of the pa­tient on a ven­ti­la­tor. Peo­ple like to do those things in a con­trolled fash­ion rather than on an emer­gency ba­sis.”

Still, the ben­e­fit of keep­ing pa­tients awake is en­tic­ing.

A 2014 Emory Univer­sity study com­pared 140 TAVR pa­tients, pri­mar­ily by the anaes­the­sia they re­ceived, and found that those with con­scious se­da­tion were less likely to die and spent two fewer days in hos­pi­tal care on av­er­age.

Doc­tors have long used con­scious se­da­tion for im­plant­ing stents, pace­mak­ers and de­fib­ril­la­tors, and now some are try­ing it in pro­ce­dures to treat atrial sep­tal de­fects – holes in the walls sep­a­rat­ing the heart’s up­per cham­bers.

Noth­nagel, who be­came Ab­bott’s se­cond case of TAVR con­scious se­da­tion, had de­vel­oped a con­di­tion called aor­tic steno­sis, which oc­curs when the aor­tic valve sticks and in­hibits blood flow.

Steno­sis grows more com­mon with age and can lead to chest pain and heart at­tacks.

He agreed to the ap­proach when So­ra­jja first asked him. The Ply­mouth re­tiree took pride in siz­ing peo­ple up dur­ing his sales and mar­ket­ing ca­reer, and he liked his doc­tor’s con­fi­dence.

As the pro­ce­dure be­gan on a re­cent Wed­nes­day, on the other side of the drape from where So­ra­jja was op­er­at­ing, Noth­nagel’s bushy eye­brows be­trayed mo­ments when he could feel the pokes and prods of the pro­ce­dure.

When So­ra­jja in­jected dye so he could see his pa­tient’s blood ves­sels on a mon­i­tor, Noth­nagel said it felt hot and tasted bit­ter.

“Wal­ter,” So­ra­jja said, us­ing his pa­tient’s for­mal name, “you are go­ing to feel your heart beat get­ting a lit­tle faster. You may even feel light- headed. The most im­por­tant thing is we don’t want you to move. Just shout if you feel any­thing.”

A puff of dye il­lu­mi­nated Noth­nagel’s aorta on a screen, and the valve im­plant that had been threaded through a five- mil­lime­ter in­ci­sion in his chest.

So­ra­jja could ex­pand the ar­ti­fi­cial valve just once, so he had to make sure it was in a spot that would push the fail­ing nat­u­ral valve aside and take over its role.

“I like the po­si­tion there,” he said to his team. “You guys like it?”

Con­scious se­da­tion was un­think­able for the first gen­er­a­tion of TAVRs, be­cause the re­place­ment valves were larger and in­serted through wider in­ci­sions.

The lat­est valves by com­pa­nies such as Ed­wards Life­sciences and Medtronic are eas­ier to im­plant.

Less anaes­the­sia also ap­pears to save money; the Emory study found TAVR pa­tients cost US$ 10,000 ( RM42,000) less when re­ceiv­ing con­scious se­da­tion, pri­mar­ily due to shorter hos­pi­tal stays.

For now, TAVRs have been re­served for pa­tients too frail for open surgery.

Risks of death and stroke dur­ing TAVRs are as high as 2% and 3%, re­spec­tively. But bet­ter re­sults with less anaes­the­sia could re­sult in the ap­proach be­com­ing more com­mon.

Min­i­mal se­da­tion was the right choice, Noth­nagel said af­ter the pro­ce­dure, be­cause he felt strong and alert. And he avoided hav­ing a breath­ing tube down his throat.

Any pres­sure or pinches dur­ing the pro­ce­dure were worth the trade- off, though af­ter a life­time of other med­i­cal pro­ce­dures, he con­sid­ers him­self a pretty tough guy.

“There’s a red S on my chest,” he said. – Star Tribune ( Min­neapo­lis)/ Tribune News Ser­vice

Anaes­the­si­ol­o­gist Tjorvi Perry ( left) talks with pa­tient Roy Noth­nagel, who re­mained con­scious dur­ing a pro­ce­dure to re­place a de­fec­tive heart valve. — TNS

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