In 'awake' surgeries, surgeons must watch what they say

Surgical team working on a patient in operating theater (iStock)

A growing number of surgeries performed with only local anesthesia create new challenges for surgeons, according to interviews with U.S. doctors.

Surgeries using new local anesthestics that numb an area of the body but leave patients awake, tend to have a shorter recovery time, but can also cause distress and anxiety for patients, researchers write in the American Journal of Surgery.

These "awake surgeries" also raise new issues for surgeons, who must balance the needs of operating room staff and patients, the authors found.

"The surgeons that we interviewed told us that having an 'awake' patient changed the way they communicated with their team," senior author Dr. Alexander Langerman told Reuters Health by email.

These changes, including using code words and limiting trainees' involvement with awake patients, were strategies surgeons developed on their own. "None had formal training in surgeon-patient communication during awake procedures," said Langerman, an assistant professor of otolaryngology at Vanderbilt University Medical Center in Nashville, Tennessee.

Langerman's team interviewed 23 surgeons in various specialties about their experiences operating on awake patients.

The surgeons talked about many surgical procedures, ranging from biopsies to abortions to cataract surgery.

They said that awake surgeries tended to be more efficient and satisfying overall and that patients were able to help with certain check-ins during procedures.

The doctors also noted some disadvantages, including the difficulty of addressing patients' pain during surgery and the possibility of patients making risky movements during the procedure.

Surgeons also found it harder to teach surgical trainees because patients were uncomfortable with the idea of a student operating on them.

Many doctors found themselves less likely to let trainees participate in procedures, a change that could have a negative long-term effect on trainees' learning, they said.

The most common type of communication between surgeon and patient that the doctors mentioned was to manage patients' expectations, including warning patients about any upcoming changes in what they might feel.

Doctors noted that they needed to choose their words more carefully and have code words for mistakes rather than saying "oops."

Surgeons were aware of the fact that operating rooms can be uncomfortable for patients. Some tried to change this by playing music or limiting the number of people moving in and out of the room.

Some doctors offered patients the option of taking sedative medications, which would not keep them unconscious like general anesthesia, but might help them relax or go to sleep.

Most surgeons had never learned how to communicate with awake patients and many felt insecure about their techniques and were interested in learning new strategies.

Dr. Lashmi Venkatraghavan, a professor at the University of Toronto who studies communication during surgery, noted the importance of reducing patient's anxiety. "All the negative events will be remembered forever by the patients and it does have a long lasting psychological effect," she told Reuters Health by email.

Venkatraghavan, who was not involved in the study, recommends that surgeons give patients full explanations of what to expect during the surgery.

Surgeons should also tell patients about their options for how to manage pain or discomfort during surgery, such as how to get additional pain medicine or local anesthesia, she said.

"I think all patients, no matter (if they're) awake or asleep, should discuss with their surgeons the plans for the operation and how trainees will be involved in their care," Langerman said, adding that patients should specify how many details they want to hear about what is happening during the surgery.

"You should ask for what you want and be prepared to negotiate with your surgeon as to what will help him or her perform at their best and keep you comfortable and satisfied during surgery," Langerman said.

SOURCE: bit.ly/2bgOTlt American Journal of Surgery, online July 29, 2016.