DEEP SLEEP?: Some anesthesiologists are arguing for a shift in the way we think--and talk--about "going under."
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Patients undergoing significant operations, such as major cardiac or transplant surgery, typically require general anesthesia. But putting patients to "sleep" might not be the best way to describe the process, argued the authors of a new review paper, published in the December 30 issue of the New England Journal of Medicine.
What anesthesiologists are really doing is closer to putting patients—close to 60,000 each day in the U.S.—into a drug-induced coma. "It's a reversible coma, but it's nevertheless a coma," says Emery Brown, a professor of anesthesiology at Harvard Medical School and coauthor of the paper.
General anesthesia before major surgery dips brain activity (as measured by electroencephalogram, or EEG) down to levels akin to brain-stem death. For the most part, Brown has found that anesthesiologists talk about the process in colloquial terms, telling patients they will be "asleep," rather than "unconscious"—likely in an effort to not make a medical ordeal any scarier than it already needs to be.
That approach is doing both patients and scientists a disservice, he argues.
"It would be nice if your anesthesiologist could explain where drugs are going to be working," Brown says. Many clinicians, however, might be hard pressed to offer detailed neurological explanations for how each compound they administer is working on the nervous system. They are more likely to think of it in terms of "we turn the knob and they go to sleep," says Michael Alkire, an associate professor of anesthesiology at the University of California, Irvine, who was not involved in the new paper.
Inducing a coma-like state does require careful monitoring, breathing and temperature support as well as a delicate balance of "hypnotic agents, inhalational agents, opioids, muscle relaxants, sedatives and cardiovascular drugs," Brown and his colleagues noted in their paper.
The mechanisms behind this concoction, carefully devised though it might be, are not always well comprehended. Long thought of as a "black box," anesthesia now "can be explained and understood—it's not a mystery," Brown says. And researchers can further help to clear the field's fog by expanding the field of anesthesiology to collaborations with experts in other fields, such as sleep and coma research.
Although anesthesiology and research on sleep and coma generally carry on independently of one another, "there's a way to think about them all in the same framework," Brown explains. And that common frame should be neuroscience, he says.
Alkire agrees that the coma model "is more appropriate," and that "shifting toward that view is going to be helpful" in moving the field forward. And bringing the disparate fields, including researchers from sleep and coma work, together makes sense because "it's all the same fundamental neuroanatomy."
A push for more detailed neuroscience in the field might also help drive research toward new, more effective methods. Diethyl ether was a revolutionary tool in the 19th century that could knock people out before surgery, but it had some unpleasant side effects. "Now we need nuance" and more targeted tools like those cropping up in other areas of medicine, such as cancer treatment and screening, Brown notes.
Anesthesia, Alkire says, "is still kind of on the level of 'we have a big hammer, and we hit you on the head, and you get knocked out.'" He and his colleagues have been working to find more "regional brain anesthesia that would change the state of consciousness," he explains. "I think we have a ways to go" he says but notes that they have had some promising leads by zeroing in on the thalamus in animal studies. But even if clinicians might not yet have more delicate tools to dip patients into surgery-ready unconsciousness, Alkire notes, "understanding how it works puts you in a position to do better anesthetics eventually—if not with the agents you have right now."
And taking a deeper look at how drugs are working during anesthesia might also yield helpful models for different neurological disorders, Brown says, noting the similarities between EEGs in patients under general anesthesia and those in comas.
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11 Comments
Add Commentgood to know this. now i am more terrified going under for surgery.
Reply | Report Abuse | Link to thisReally fascinating. Question: what happens to the electrical states in the brain Vs biochemical? I'm thinking about micro, not macro as in EEG monitoring.
Reply | Report Abuse | Link to thisIt would be helpful if the difference between a coma and sleep were explained. I appreciate that they are different but those differences seem to be key to this article so a little summary would have been worth while.
Reply | Report Abuse | Link to thisWell the idiot who killed Michael Jackson certainly didn't understand. Using a general anesthetic like propofol to help someone sleep is idiotic and obviously dangerous. If you have heard the term drug induced coma (DIC) for brain injury, it is clear that not being awake isn't the same as sleeping. Brain activity is severely depressed during GA (general anesthesia) but at times very active during the 5 or so stages of sleep. During a head injury a DIC is supposed to greatly limit the metabolism of the brain, sleep does not. How this became news is the real mystery. I would hope that most doc's if not all would know that GA is not the same as sleep.
Reply | Report Abuse | Link to thisIt might be nice if the surgical team actually divulged to the putative patient what is going on.
Reply | Report Abuse | Link to this'Pump head" is hardly news... and telling people that anesthesia is likely to result in nigh-on-to-permanent brain damage.... is not a "side effect".. but a serious danger.
But, of course... this would tend to make people less likely to indulge in vastly expensive and money-making procedures.... that also "just happen" to boost the egos of notably egostistical surgeons.
We already know from the studies done by Tversky and Kahneman on the psychology of choice that "doctors" are among those who are utterly lacking in objectivity in desision-making,, including, and most alarmingly.. in their field of suppsoed expertise.
Those in the world of finance, banking, taxation and con-artistry also know this to be true... there is no one so obtusely unable to make sensible decisions in money-matters than your "typical doctor or dentist".
Among other reasons.. this is why our healthcare systems hemorrhage money.. and we commonly see those who hold "extra good health care coverage" to be basket cases of medical intervention which tends to only require still more of the same.
Well, wish I hadn't read this! I have been under a couple of times and believed it was not as serious as described in this article. Too bad I have bad genetics! Best of luck to everyone who need GA!
Reply | Report Abuse | Link to this"Traditional treatments often work on the same mechanisms as the drugs given to anesthetize patients before surgery..."
Reply | Report Abuse | Link to thisI'm interested in what the exceptions to "often" are.
Your statement is indeed very thrue.
Reply | Report Abuse | Link to thisOnly a half witted person should use propofol as a remedy for curing insomnia!
Propofol is for profesional use only, and then an excelent drug for anaesthesiainduction.
Poorly educated and bitter, what a nice combination you have made of yourself. Other than hating surgeons, do you have anything useful to say?
Reply | Report Abuse | Link to this"I'm interested in what the exceptions to "often" are."
Reply | Report Abuse | Link to this"It would be helpful if the difference between a coma and sleep were explained."
"what happens to the electrical states in the brain Vs biochemical?"
Three or four more paragraphs and this article might have been worth reading.
I agree with this article. I have had full anaesthesia on
Reply | Report Abuse | Link to thisa number of occasions. As side effects for a time afterwards I have difficulty remembering words it normally takes up to 3 months to come right. In addition
my blood sugar level go crazy and exceed the norm. I am still monitoring my sugar level more than 2 months after the last medical procedure. Should I be concerned about this?
Serge Dumont