Ventilator-Assisted Living©

Fall 2003, Vol. 17, No. 3

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Sedation for Surgery

Lawrence C. Becker, Roanoke, Virginia

sketch of Larry BeckerAfter 45 post-polio years of avoiding surgery altogether, I have recently been forced into two significant surgical procedures. One was an emergency gallbladder operation (1999), performed laparoscopically under general anesthesia in a small community hospital. I was intubated, but was back using my BiPAP® S/T (www.respironics.com) three hours after the surgery. The other was a radio frequency (RF) cardiac ablation (May 2003) to correct a persistent arrhythmia called supraventricular tachycardia (SVT). This second procedure was performed under sedation (sometimes heavy), using my own BiPAP for mechanical ventilation, in a large, busy, regional medical center with teaching obligations.

Both surgeries went well, and, oddly enough, each lasted 2½ hours. The first was life-saving and not optional. The second got me off some drugs that had been compromising my energy and stamina for 10 years, making it hard to distinguish the side effects of the drug from the late effects of polio. The cardiac ablation also eliminated my increasingly frequent trips to the ER when the medications weren’t sufficient.

The moral seems to be that recent advances in minimally invasive surgery provide new options. Cardiac ablation carries some risks, but so did the attempts to manage episodes of arrhythmia with drugs. Weighing the two sets of risks carefully, without prejudice, was essential. That was easier said than done because I’ve gone out of my way to avoid surgical options for many years, just on general principles. I’m now learning to be more reasonable about this.

There are still some special precautions ventilator users and perhaps polio survivors in general need to take when considering surgery. (See “Before Surgery”) But in my recent experience, medical professionals are now ready to hear and to accommodate our insistence on noninvasive ventilation whenever appropriate. My physicians have also been willing to add (again on request) the extra layers of protection I might need during surgery and other procedures performed under sedation, such as endoscopic examinations or colonoscopy. My cardiac ablation surgery illustrates all those points.

RF cardiac ablation. Some arrhythmias are essentially wiring problems, due to alternative electrical pathways in the heart muscle. When these alternative pathways are activated, the heart may beat very rapidly but in a relatively controlled way (as in my case) or in a more disorganized and dangerous way. If the episodes are rare and brief, no treatment may be needed. Otherwise, various drug therapies are available to reduce their frequency. If the drugs fail or if, again in my case, high dosages of the most powerful available drugs cannot be tolerated, additional measures can be taken, but only in the ER. Most of these are temporary measures to convert the arrhythmia to a “normal sinus rhythm.”

For SVT there is a surgical cure, known as radio frequency cardiac ablation. Catheters with small instruments are inserted into the right atrium of the heart through one of the femoral veins and, if necessary, into the left atrium through a femoral artery. The electrical circuitry of the heart is then “mapped,” and when the offending alternative pathways are found, they are ablated – burned away. Most of the details are unimportant here. Suffice it to say that the procedure requires specially trained cardiologists and a fully equipped electrophysiology lab. It is performed under sedation and local anesthetic at the insertion site. People who can breathe in the normal way sleep through it supported only by nasal oxygen. The procedure normally lasts between two to three hours, but can take significantly longer in difficult cases. The success rate is 90% to 95%, and the rate of serious complications is under 3% nationally, though for some especially skillful cardiologists (mine included) the complication rate can be under 1%.

I slept throughout my 2½ hour procedure, using my own BiPAP with oxygen. The anesthesiologist timed things so that I was wide awake, able to breathe on my own for the trip back to my room, and to be watchful about the transfers, positioning, and subsequent (immediate!) return to using BiPAP.

The ablation went smoothly and was completely successful. Recovery time was trivial (I went back to my office on Friday after surgery on Wednesday), and there were no complications.

Lessons. Can this experience be generalized to other procedures? Yes. It generalizes to many diagnostic procedures that use sedation and to surgery performed with a combination of regional or local anesthetics plus sedation. I’m certainly not going to go looking for such opportunities, but I no longer regard them with as much apprehension.

One general caution. Sedation for these procedures is often handled by specially trained nurses. It took some persistence and flexibility on the part of my cardiologist to get what he wanted in the way of a consultation with an anesthesiologist – and that did not occur until half an hour before the procedure. An anesthesia consultation had been arranged when I had pre-surgical blood work and history taken the day before the ablation, but it did not happen. Nor did it happen early the next day, when I came back. These may have been entirely local problems, but the lesson to learn is persistence.

And humility. The anesthesiologist who was eventually assigned to my case was extraordinarily good – not only technically proficient but kind, attentive, and wise. The most important thing I learned was the necessity for him to be prepared to do more for me than my BiPAP could do, in the event that unexpected things happened. He described exactly how he would proceed short of full intubation. He had also read the records of my emergency gallbladder surgery and was prepared to replicate relevant parts of that if needed. All of this was quite reasonable. I had been so insistent on noninvasive techniques that I had not thought about backup procedures – even though I knew very well that one of the rare complications of cardiac ablations yields a pretty colorful emergency.

I’m very glad I chose to have the ablation. The best thing, of course, is being free of the episodes of arrhythmia and the trips to the ER. The next best thing is being free of the side effects of the calcium channel blocker (Cardizem) I had been taking. I had not fully realized, until I came off of the medication, how much it was compromising my limited reserves. I feel 10 years younger, breathing is easier, my balance is somewhat better, and I have more energy.

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