Awake During Surgery: How the OR Changes When You're Not Under General Anesthesia

For some, the phrase “awake during surgery” conjures images of groggily coming to in the midst of highly complicated procedures, surgical tools buzzing away as you lie there in a frozen panic. But did you know there are surgeries during which patients are intentionally left awake?

While the body areas being operated on are completely numbed and other precautions may be taken, some surgeries do not require patients to be put under general anesthesia. During procedures like these, you have to imagine the operating room (OR) changes pretty significantly to help patients remain comfortable and calm.

We consulted some medical pros who are no strangers to the OR and asked them about the precautions taken when patients are awake on the surgical table. Here’s what we learned.

Which surgeries take place while a patient is awake?

While most surgeries are performed on patients who are put under with general anesthesia, there are a number of different procedures that can be performed while the patients are awake. It’s important to note that in many of these cases, patients receive some form of sedation to calm their nerves, explains Nick Angelis, nurse anesthetist and author of How to Succeed in Anesthesia School.

Let’s get familiar with some of the most common surgeries in which a patient remains awake.

Cesarean section

One of the most routine of these surgeries is the cesarean section — more commonly referred to as a c-section. This surgery, which is sometimes scheduled in advance and other times performed in emergency situations, is performed to deliver a baby through the abdomen. About 32 percent of all U.S. deliveries are c-sections and, in most cases, the mother remains awake during the procedure while her body is numbed.

Cosmetic surgery

Some types of cosmetic facial surgery are also performed while the patient is awake, using only local anesthesia to numb the area being operated on, according to Houtan Chaboki, board certified facial plastic surgeon. “Upper eyelid surgery (blepharoplasty) is the most common procedure I perform via local anesthesia,” he explains. Patients will remain awake when they opt to not receive any oral or IV sedation.

Arthroscopy

Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a joint, like in cases of rotator cuff tendon tears in the shoulder and meniscal cartilage tears in the knee. During these procedures, surgeons will make small incisions in the patient’s skin and insert pencil-sized instruments that contain small lenses and lights so they can track the patient’s movements through digital imaging on a screen. This streamlined process allows for minimally invasive surgeries that won’t leave large scars.

If the operation will be lengthy, patients may be put under general anesthesia, but in many cases local or regional anesthesia will be used while the patient remains awake. Some patients may even opt to watch their surgeries in real-time on a screen!

Brain surgery

Some brain surgeries require patients to remain awake so doctors can assess question-and-response reactions throughout the procedure. When removing a complicated brain tumor, for example, neurosurgeons will stimulate areas of the brain that surround the tumor with small electrodes. To precisely locate the functional areas of the brain that must be avoided, the surgeon then asks the patient to perform certain tasks, such as talking, counting or looking at pictures, as listed on the website for the Johns Hopkins neurology and neurosurgery unit.

Depending on the specific procedure and the patient being operated on, the type of anesthesia or sedation used will vary. Some patients remain awake during the entire procedure while others are sedated or put to sleep at the beginning and end of the procedure while being fully awake in the middle. In all cases, patients receive a nerve or scalp block, which blocks pain, and the area being operated on is numbed.

How does the OR change when the patient is awake on the table?

For those who aren’t familiar with the environment or the procedures, the OR can be a fear-inducing place. This is why, as mentioned above, some form of sedation is often used even when patients aren’t put to sleep with general anesthesia. This helps calm nerves that commonly come with the tension of knowing you’re being operated on and potentially hearing the sounds of surgical saws or drills, Angelis explains.

But there are other things surgical teams do to make their patients more comfortable when they’re awake on the table, beyond sedation. Much of this falls to the role of the anesthesiologist and/or nurse anesthetists. These professionals are tasked with keeping the patients comfortable, awake and alert. They not only monitor vitals throughout, but also coach the patients throughout the procedures, keep them informed on the progress and often assist in transporting the patients to the intensive care unit following surgery.

There are some general do’s and don’ts, Angelis explains, noting that any music being played in the background will not be as loud if the patient is awake. He adds that the surgeons will also be less likely to “slip up” by swearing, yelling or saying “Oops” throughout the procedure.

“Staff avoid using terms like blood or pain,” Chaboki adds. “Sudden noises, such as instruments on the tray, are avoided, too.”

There are other things the medical personnel in the OR can do to personalize the situation for the patient. Chaboki makes it a point to converse with his patients when possible if the patient desires to talk. They’ll discuss menial things like recent movies, travel or other topics to keep the patient comfortable.

Angelis likes to use a warm air blower to keep the patient cozy and comfortable, while also giving the patient books, their favorite music or even his own cell phone to play with when appropriate.

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