At the hospital of Châlon-sur-Saône (Saône-et-Loire), André Garnier, a 94-year-old man was operated on for the carotid artery, even though 2 injections of anesthetic product against the pain had no effect. effects. Despite the patient’s cries, the surgeon continued to operate. This story rightly agitates social networks. Is it possible to operate without anesthesia?
Carotid arteries almost blocked by atheroma plaques, after several strokes at a minimum, but heralding a serious accident, Alain Garnier, 94, had to resolve to undergo surgery. He told what is more like an ordeal in the Journal of the Saône-et-Loire, Thursday February 15.
Unbearable pain
The operation aimed at unblocking one of the 2 carotid arteries, at the origin of the disorders, was performed under locoregional anesthesia. So far nothing unusual. But the pain quickly became unbearable during the operation, clearly reflecting a failure, at least partially, of the locoregional anesthesia.
Faced with his repeated howling and his increasing agitation, a second dose of anesthetic was injected into him without more success. Despite the unbearable suffering inflicted on Alain, the surgeon refused to interrupt the operation: “I have started, I must finish”. The anesthesiologist did not seem to do sedation or general anesthesia, which would have been another solution.
Fortunately, the operation ended well, but the patient and his wife had no explanation and, traumatized, Alain Garnier would rather die than have the other carotid artery operated on (also almost blocked).
A usual operation
The operation for a narrowing, or “stenosis”, of the carotid artery, consists in removing the atheromatous plaque, with its debris and its clots, which almost completely block one or both carotid arteries at the origin of the disease. irrigation of the brain.
This surgery is called a carotid endarterectomy because we remove only the internal part of the artery (intima + part of the media). Carotid surgery is the most effective treatment for carotid stenosis at high risk for stroke, or when there have been minor episodes of stroke.
An operation of about 2h00
After incision of the skin and release of the artery, the surgeon interrupts the circulation in the carotid artery using “clamps” upstream and downstream of the stenosis (a clamp is a metal instrument which allows the artery to be pinched. so as to prevent blood from passing).
Under locoregional anesthesia, the anesthesiologist talks with the operated patient to be sure that the brain is receiving enough blood from the other carotid artery and from other arteries after clamping of the diseased artery: there are indeed substitution systems, but the risk is that they are also blocked. This is why we prefer that the patient be conscious.
The surgeon then opens the carotid artery and removes the atheromatous plaque, as well as all the debris, then he carefully closes the artery using a very fine wire. As soon as the artery is closed, the surgeon removes the clamps to restore blood circulation in the opened carotid artery.
General or regional anesthesia
The carotid artery operation can be performed under general anesthesia or locoregional anesthesia. General anesthesia consists of completely lulling the patient and ventilating him artificially. In a 94-year-old person, who inevitably has other diseases, it is likely that the choice of locoregional anesthesia is preferable to limit the operative risks. However, several studies have demonstrated the equivalence of the 2 techniques with patients as old as this, or even lower risks with locoregional anesthesia.
In the case of locoregional anesthesia, before the operation, a drug is injected into the patient (premedication) in order to lift his anxiety and allow him to be relaxed. Locoregional anesthesia consists of injecting an anesthetic product in contact with certain nerves in the neck, which eliminates the pain at this level. Outside of this testing period, the anesthetist injects medication if necessary to allow the patient to doze off.
What happened ?
In general, local or locoregional anesthesia is well accepted by patients. Usually, small doses of the strong opioid, fentanyl, are sufficient to calm people who are struggling with the stress of the procedure. But it is always possible that ill-informed patients remain very anxious.
On the other hand, it sometimes happens that particularly anxious patients, and without sedative premedication, are in such a state that the block and the operation are impossible to perform. We then resort to strong sedation with a drug, propofol, which allows the surgeon to complete the locoregional anesthesia by meticulously infiltrating the sheath which surrounds the carotids and which, being very tight, can limit the diffusion of anesthetic products. It is also possible to convert a locoregional anesthesia into general anesthesia. This is why an anesthesiologist is always there.
Rarity of resistance to anesthesia
Resistance to locoregional anesthesia is very rare when it is well achieved: less than 3 per thousand in a very large Italian series, and in this case, the anesthesiologist can immediately initiate a general anesthesia procedure in order to avoid any suffering to the patient and to allow the surgeon to operate correctly. This was not done with Alain Garnier, perhaps due to contraindications to general anesthesia.
The Châlon-sur-Saône hospital may well take refuge behind medical confidentiality, a secret which is not, moreover, opposable to the patient, and affirm that “all safety measures in the operating room have been taken to ensure the good health of the patient “, a superb sentence which smacks of the language of wood, he should immediately explain well to Alain Garnier and his family what happened, it is the best way to avoid the trouble.
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