Would you go under the surgeon's knife AWAKE if it cut your wait time?

Would you go under the surgeon’s knife WIDE AWAKE if it cut your waiting time for an operation? Fears that having a general anaesthetic can spread Covid-19 have led to a massive backlog of cases… but now the NHS is trialling a radical new approach

When Guy Levy was told he needed hernia surgery earlier this month, his first question was not about the safety of the operation at this time but: ‘Can I have it done under a local anaesthetic?’

Guy was determined not to have a general anaesthetic, even though this is the most common way to carry out the procedure. 

‘This was my 17th operation — I nearly died in a motorbike accident in 2006 and needed multiple operations to save my life,’ he says. 

Around 20 per cent of the 3.5 million anaesthetics given in the NHS each year are local or regional anaesthetics, which just numb a specific area. It’s estimated this could double with the new plan

‘I would never have a general anaesthetic unless the procedure was critical.

‘A local anaesthetic doesn’t have all the unpleasant side-effects and the recovery is quicker — on one occasion, I remember having awful hallucinations with a general anaesthetic.

‘I wasn’t worried about Covid. Before the operation I was screened [on the second day of lockdown] and I was reassured by the measures the hospital put in place to keep it virus-free.’

Delays in numbers

3.6m over-50s had operations or treatments cancelled in the first lockdown, according to the Institute for Fiscal Studies.

444,828 patients were waiting for ophthalmology treatment including cataract surgery, according to Labour party analysis of NHS data released in September.

302,426 patients were waiting for orthopaedic and trauma surgery (including hip and knee ops) for over 18 weeks, the British Orthopaedic Association said in August.

140,000 people waited over a year for hospital treatment in September — 107 times the September 2019, NHS England figures show. 

For the 45-minute procedure, a local anaesthetic was injected into the left side of his lower body. He was also sedated, so has no recollection of the operation.

‘I went into hospital around 8am, had the operation two hours later and went home late afternoon, although I could have probably gone home earlier if I’d wanted,’ says Guy, 51, who works in research and development in digital media and is from London.

‘I haven’t taken any painkillers and the wound is healing nicely. It all went extremely smoothly.’

Colin Elton, a consultant surgeon at the Royal Free London NHS Foundation Trust and at HCA Healthcare, who operated on Guy as a private patient, says only a ‘small minority’ of hernia repairs are carried out under a local anaesthetic, although the outcomes are good and more could be done this way.

As Good Health can reveal exclusively, thousands of patients are now being encouraged to go down this route, both to slash mounting NHS waiting lists and reduce the risk of Covid-19.

Around 20 per cent of the 3.5 million anaesthetics given in the NHS each year are local or regional anaesthetics, which just numb a specific area.

It’s estimated this could double with the new plan, which will target common surgery such as knee and hip replacement and cataract removal. 

London hospitals trying it first 

Under the new drive, being piloted in 27 NHS hospitals across London until April 2021, fast-track surgical hubs are being introduced for patients needing 29 ‘low-complexity surgical procedures’.

In the first part of the initiative, patients having cataract surgery will be encouraged to have it under a local anaesthetic. This is expected to soon be rolled out to other procedures.

The move comes amid an ongoing debate about the risks of spreading Covid-19 by intubating patients — a procedure carried out in half of all general anaesthetics, where a tube is put down a patient’s throat so a machine can breathe for them during the operation. 

Some studies show that inserting and removing a breathing tube produces aerosols, tiny air particles that can potentially spread Covid-19 to theatre staff.

Certain surgical procedures are also thought to create aerosols — these include colonoscopies, laparoscopies (keyhole surgery in the abdomen) and gastrointestinal surgery, as well as ventilation techniques (such as breathing masks used for general anaesthetics).

However, other research suggests that aerosol production is minimal with these techniques and that the risk of Covid-19 from operations has been overstated, with operations having been unnecessarily cancelled, and causing needless delays to operations by theatre staff having to wear full personal protective equipment (PPE) during surgery, and special cleaning procedures being introduced.

The debate about the potential risks of Covid-19 from intubating patients could be circumvented by the new drive, as doctors have been ordered to avoid general anaesthetics where possible. This would also speed up surgery itself because fewer precautions are needed with local anaesthetics.

Some studies show that inserting and removing a breathing tube produces aerosols, tiny air particles that can potentially spread Covid-19 to theatre staff

Having to wear full PPE and enhanced theatre cleaning has led to a 50 per cent reduction in capacity for surgical procedures, contributing to long NHS waiting times, says Professor Andrew Klein, a cardiothoracic anaesthetist at Royal Papworth Hospital in Cambridge.

The latest figures, for September, show there were 4.35 million people in England waiting for NHS treatment, with predictions that this could rise to ten million by the end of the year.

Waiting times have spiralled to the highest level in 12 years, according to NHS figures.

As well as speeding up surgery, a local or regional anaesthetic is associated with quicker recovery for patients and with fewer side-effects such as chest infections, sickness and vomiting. This would mean less time in hospital.

Recent research has also shown that patients having a local anaesthetic are less likely to contract Covid-19 at the time of surgery. A study of 166 patients undergoing urgent orthopaedic procedures, published in the journal General Orthopaedics in September, found that 27 per cent of those having a spinal anaesthetic and 13 per cent of those having a general anaesthetic caught the virus in the week before or two weeks after surgery, compared with just 1.3 per cent of those having a local anaesthetic.

‘Opting for local anaesthetic over general anaesthetic can help patients mobilise more quickly after surgery; and reduces the risk to the public and NHS staff of exposure to coronavirus,’ says Professor Tim Briggs, senior clinical lead for the NHS elective surgery and transformation programme, who is involved in the local anaesthetic pilot study.

If the initiative is successful, it could be rolled out nationwide. 

Fewer side-effects for patients 

Many routine operations can be done safely under a local or regional anaesthetic, according to Professor William Harrop-Griffiths, a consultant anaesthetist at Imperial College Healthcare NHS Trust in London and vice-president of the Royal College of Anaesthetists. 

These include hip and knee replacements, some hernia operations, minor gynaecological procedures and surgery for piles, as well as shoulder, arm, hand, knee and foot injuries.

While there has already been a move in recent years to increase the number of operations done under local anaesthetic, the pandemic has ‘accelerated changes that were probably inevitable’, says Professor Harrop-Griffiths.

‘General anaesthesia has always been the default anaesthetic in this country. Most members of the public expect a general if they are to undergo anything more than minor surgery.

‘Many anaesthetists also prefer it because by the end of their training in the UK, all are experts at giving generals and spinal anaesthetics, but not all are experts at giving regional anaesthetics for arms and legs, although this is changing. However, many minor operations can be done under local anaesthetic — these generally involve the lower half of the body and arms.

‘In some cases, these procedures are already done under local anaesthetic but the new initiative is to increase the number.’

He adds that ‘there is an increasing number of studies that show that regional is often superior; the pain relief is better because the part of the body stays numb and pain-free for a while, and many common complications of a general, such as nausea, vomiting and dental damage are avoided.’

Bigger impact on minor procedures

‘Carrying out more procedures this way would also speed everything up, and help us to start clearing the backlog of operations that the pandemic has created,’ says Professor Harrop-Griffiths.

And the shorter the procedure, the greater the impact on waiting lists, he adds. ‘It’s when all the extra precautions and PPE are needed for shorter procedures that it really slows us down and many of these procedures can be done under local anaesthetic.

‘The surgery itself may only be ten minutes, but waiting 20 minutes before and after surgery for any aerosols to clear means the procedure can take nearly an hour. Reducing the length of a major heart operation that takes several hours by 20 minutes is not going to make a big difference. But reducing the time of a breast lump removal or hernia repair would have a huge impact and allow us to carry out many more operations.’

He adds: ‘Many routine operations can be done under a local and there are good reasons for carrying out surgery this way.

‘Put it this way, as a man over the age of 60 in a time when Covid-19 prevalence is increasing, I would feel safer having my surgery under local anaesthesia than general anaesthesia.’

Doctors are divided about the Covid risks of general anaesthesia, specifically intubating and extubating (removing the tube at the end of surgery) patients.

The debate is about aerosols, tiny air particles known to transmit all manner of bugs and viruses, including coronavirus — and the risk rises with any procedures involving the airways, making dentistry and ear, nose and throat operations particular causes for concern.

Aerosol-generating procedures are defined by Public Health England as procedures that generate more aerosols than a cough. ‘There are three ways to get Covid: person-to-person contact, droplets and aerosols,’ says Professor William Harrop-Griffiths, a consultant anaesthetist and vice-president of the Royal College of Anaesthetists.

If you cough, a droplet can travel two metres through the air — ‘but because it is quite big and heavy, it will then drop to the ground’, he adds. ‘Aerosols are much smaller particles that float like dust and have far greater capacity to stick around.’

If the patient has tested positive for Covid, or there is no time to test them, all theatre staff have to wear full PPE, which is uncomfortable and difficult to communicate in.

Furthermore, once intubation has been carried out, there has to be a 20-minute pause before starting surgery while the air-flow system in the operating room, which exchanges air at regular intervals to keep air in the operating theatre clean, goes through a cycle.

This is followed by a further 20-minute wait at the end of the procedure again to clean the air before transferring the patient to the recovery area. Special cleaning of the theatre takes place between each operation.

But research published last month in the journal Anaesthesia suggested this cautious approach was unfounded. Intubating patients may produce only a fraction of the aerosols than previously thought, it found, and much less than that produced during a single cough. 

This suggested all operations involving intubation had been unnecessarily delayed by a misplaced assumption about the Covid-19 risk. 

In the study, Dr Jules Brown, an anaesthetist, and his colleagues at North Bristol NHS Trust measured the airborne particles produced in routine anaesthetic procedures in patients undergoing urgent orthopaedic or neurosurgery.

They also found that ‘mask ventilation’ before tube insertion produced barely any aerosols.

Aerosol measurements were recorded for 19 tube insertions and 14 tube removals in June and July. They found inserting the breathing tube produced barely any aerosols — approximately one thousandth of the aerosol generated by a single cough.

Although removing the tube did generate more aerosols if the patient also coughed, the amount was less than a quarter of that produced by a normal cough.

However, in a much smaller study, published weeks later also in the journal Anaesthesia, Australian researchers recorded aerosol production in three operations.

Both teams stand by their findings but are now collaborating on a new study of 15 patients, which they hope will provide the definitive answer. The results should be published by the end of the year.

‘These findings should trigger a debate about a need for the current enhanced measures to protect against airborne spread in operating theatres,’ says Tony Pickering, an anaesthetist and professor of neuroscience and anaesthesia at Bristol University, who also took part in the study.

‘If a de-escalation of the protective measures was enacted, which our findings support, then this could greatly improve our ability to deliver healthcare to patients within the NHS and internationally.’

The Royal College of Anaesthetists agreed, saying that reclassifying these procedures would ‘save time, speed up the delivery of care to patients in the operating theatre and greatly increase the NHS’s ability to deliver planned surgery care’.

Public Health England has to decide on a change of rules. Until there is more concrete evidence, the safest option may be a local anaesthetic where possible, says Professor Harrop-Griffiths.

Source: Read Full Article