By Dr. Kenneth Kim, Board-Certified Plastic Surgeon, Los Angeles, CA

While initially a remarkable achievement, general anesthesia hasn’t made any significant advancements in over a century. Although general anesthesia was an incredible breakthrough in enabling complex surgeries and medical procedures with patient comfort and safety in mind, recent research has shed light on a concerning aspect of anesthesia's effects: memory loss and cognitive dysfunction.

The implications of this revelation are profound. Memory is the cornerstone of our existence, woven intricately into the tapestry of our identities. With each new finding and concern made in present research, why aren’t more medical practitioners questioning the common use of general anesthesia when it’s not necessary?

Fortunately, with supported research, there have been significant findings in an alternative to general anesthesia: awake surgery. A safer alternative that promises to preserve memory while ensuring successful medical interventions all while taking the patient’s comfort and safety in mind.

General anesthesia and memory impairment

Initially, research focused on the immediate postoperative period, where transient memory loss — known as postoperative cognitive dysfunction (POCD) — is a recognized phenomenon that may last for a few days or weeks. However, deeper concerns have surfaced as investigations delved into potential long-term permanent cognitive decline associated with anesthesia exposure.

As the global population ages and surgical interventions become more prevalent among older individuals, the implications of anesthesia-related cognitive decline become more pressing. Researchers have observed that advanced age is a significant risk factor for memory loss after anesthesia. Moreover, patients with pre-existing cognitive impairments, such as mild cognitive impairment (MCI), may be more vulnerable to anesthesia's deleterious effects on memory.

Notably, a groundbreaking study from 2014 published in the National Library of Medicine with a study group of 24,901 patients aged 50 years and older found that older patients who undergo surgery with general anesthesia are at an increased risk of dementia. A more recent study confirms the same findings that cognitive impairment is highly associated with older patients who had surgery with general anesthesia.

Numerous animal studies have shown that general anesthesia kills brain cells in the hippocampus, the region of the brain that is involved in memory formation. The mechanism involves disrupting the mitochondria function, membrane permeability, and cell death.

In the pursuit of safer medical interventions, anesthesia providers and surgeons must be diligent in assessing each patient's unique risk factors and medical history to make informed decisions regarding anesthesia management. Additionally, continued research and collaboration are essential to advancing our understanding of anesthesia's impact on memory and cognitive function, paving the way for safer and more cognitively protective approaches to medical care.

Understanding the risks of general anesthesia

As the connection between general anesthesia and memory impairment gains prominence, it becomes vital to delve into the various anesthetic risks that may contribute to this phenomenon. Although anesthesia is generally considered safe, certain factors can heighten the likelihood of memory loss and cognitive complications, particularly in vulnerable individuals.

Advanced age emerges as one of the most significant risk factors for memory impairment following anesthesia, as the brain undergoes natural changes, including a gradual decline in cognitive function. The impact of anesthesia on an aging brain can exacerbate cognitive vulnerabilities, leading to an increased risk of POCD.

Furthermore, the presence of pre-existing cognitive impairments significantly raises the risk for individuals exposed to general anesthesia. Conditions like Alzheimer's disease or other forms of dementia may render the brain more susceptible to the effects of anesthesia, potentially resulting in greater cognitive decline after surgery. Additionally, patients with pre-existing cognitive impairment may face greater challenges in recovering cognitive function during the postoperative period, highlighting the importance of individualized risk assessment and tailored care.

With general anesthesia, you lose neurons and they don’t grow back. A study in 2017 explored this concept and found that while it is commonly known in the medical world, evidence suggested that “a single exposure to anesthesia leads to widespread neuronal cell death throughout the brain.” A more recent study confirms the same finding through comprehensive research.

A safe alternative to general anesthesia

In response to mounting concerns about general anesthesia's impact on memory and cognitive function, medical professionals and researchers have turned their attention to a compelling alternative: awake surgery. Also known as "local anesthesia," awake surgery offers a safer approach that aims to mitigate the risks of memory loss and cognitive complications associated with general anesthesia while ensuring successful medical interventions.

Awake surgery introduces a paradigm shift in medical practice, allowing patients to remain conscious and engaged during certain surgical procedures. Unlike general anesthesia, which induces a temporary coma-like state, awake surgery utilizes local anesthesia to numb the targeted area while maintaining the patient's awareness. This approach not only provides a safer option for specific surgeries but also allows for a deeper understanding of the patient's experiences during the procedure.

One of the most significant advantages of awake surgery is its potential to avoid critical complications associated with general anesthesia. By not inducing a coma-like state, awake surgery eliminates the risk of fatal blood clots that can occur due to prolonged immobilization under general anesthesia. Additionally, by avoiding general anesthesia, the risk of memory loss and cognitive impairment is significantly reduced, particularly for vulnerable individuals, such as the elderly or those with pre-existing cognitive conditions.

Beyond its cognitive benefits, awake surgery also offers notable advantages in terms of patient comfort and recovery. Patients undergoing awake surgery experience less pain during the procedure as the targeted area is anesthetized. Consequently, there is a reduced need for postoperative pain management, including opioids, potentially contributing to the broader efforts to combat the opioid epidemic in America.

Moreover, the absence of general anesthesia-induced physiological changes allows for faster postoperative recovery. Awake surgery patients are generally able to resume their daily activities sooner, improving overall patient satisfaction and reducing the burden on healthcare resources.

The mounting evidence pointing to the cognitive benefits of awake surgery calls for a collective commitment to advancing medical knowledge in this domain. Embracing awake surgery not only transforms patient safety and comfort, but also contributes to addressing broader public health issues.

Dr. Kenneth Kim is a board-certified plastic and reconstructive surgeon practicing in Los Angeles. Dr. Kim was nominated for the Rhodes Scholarship and selected as a University Medal finalist at UC Berkeley. Dr. Kim graduated from Yale University School of Medicine and was a recipient of the Dean’s Award and Department of Surgery Research Award. Dr. Kim was inducted as a fellow at the Howard Hughes Medical Institute. He completed his plastic and reconstructive surgery residency at Northwestern University. Dr. Kim was awarded the AO Craniomaxillofacial Research and Development Fellowship at the AO Institute in Switzerland. He is an assistant clinical professor at UCLA School of Medicine, a partner of Dream Medical Group in Seoul, South Korea, and a clinical faculty at Seoul National University. He has published numerous peer-reviewed journals and serves as reviewer for multiple surgical journals. Dr. Kim lectures at national and international plastic surgery conferences on the dangers of general anesthesia, especially how it affects memory. Dr. Kim believes in the importance of performing awake surgery without changing patients’ physiology to provide the safest surgery possible. He is a pioneer and a leading expert in awake plastic surgery. Dr. Kim focuses on eyelid, facelift, rhinoplasty, and breast surgeries.