This document discusses the benefits and risks of regional anesthesia. It notes that regional anesthesia provides significant benefits for patients such as better pain control, reduced complications, and faster recovery. However, risks are also present though low. The document emphasizes taking a pragmatic approach that balances the benefits and risks for each individual patient. It also stresses the importance of clear explanation and documentation of informed consent. Proper training, use of standardized techniques, and a focus on patient safety are recommended to maximize benefits and minimize risks.
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Balancing Risks and Benefits of Regional Anaesthesia
1. Colin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of Anaesthesia
and Pain Medicine
University of Ottawa
Head of Anaesthesia
The Ottawa Hospital
Scientist,
Ottawa Hospital Research Institute
Balancing risk and benefit
with regional anaesthesia
4. Summary
Regional anaesthesia provides significant
benefits for our patients
A pragmatic approach that balances
benefit and risk is needed
Clear explanation and documentation of
informed consent is important
5. Benefits of Regional Anaesthesia
Better pain control (Rigg et al 2002, Park et al 2001)
Improved quality of life and exercise
tolerance (Carli et al 2002)
Reduction in respiratory complications
(Ballantyne et al 1998)
Faster return of GI function (Steinbrook RA 1998)
Improved tissue oxygenation (Buggy et al 2004)
Faster discharge (McCartney et al Anesthesiology 2004)
Less PONV (Chan VW et al 2001)
Less chronic pain (Katz et al 1994)
Improved morbidity and mortality (Memtsoudis 2012,
Pugely 2013)
8. Value of RA on pain
McCartney, Brull et al 2004
9.
10. Value of RA on adverse events
McCartney, Brull et al 2004
11.
12. What are other benefits of RA?
Improved resp fnctn (Ballantyne et al)
Faster return of GI function (Liu SS et al)
Improved early ambulation (Ilfeld et al)
Better sleep (Riazi S et al 2008)
13. Regional Anaesthesia
and Big Data
Reduction in surgical site infection
Reduced critical care utilization
Faster discharge
Reduced readmission
Reduction in mortality
16. 400 hospitals between 2006-10
Data from primary hip/knee arthroplasty
Subgrouped by anesthetic technique
30 day morbidity and mortality data
Anesthesiology 2013
17. 382,000 patients
25% neuraxial
Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013
23. 23 RCTs in total
Pooled 3 studies for epidural after
thoracotomy and 2 for PVB after breast
surgery
Unable to pool data from other studies
due to marked heterogeneity
26. My own experience
Edinburgh and Bruce Scott
Dundee and Bill Macrae
Aberdeen and Alistair Chambers
Toronto and and Vincent Chan
Multiple patients over 25 years
35. RA Risks: Central Techniques
Neuropathy 2-3/10,000
Haematoma 12.3/100,000
Abscess 73/100,000
Paraplegia or Death 0.7-1.8/100,000
Brull R et al 2005
Cook TM et al 2009
Cameron CM et al 2007
36. RA risks: PNB
Seizures (5-20/10,000)
Cardiac complications
Pneumothorax (up to 6%)
Respiratory failure
Eye injuries
Nerve injury (3-30/10,000)
Death (1 case LPB)
Auroy Y 2002
37. Complications: Minor
Pain during block performance
Painful paresthesiae
Post-block bruising/hematoma
Intravascular injection
(tachycardia/hypertension)
38.
39.
40.
41. Prevention and Management of
RA Risks
Documented informed consent
Balance of benefit vs risk
Standardization of process and technique
Just culture and learning from error
Good training and use of effective
technique
Doctor: Patient relationship
42. Informed Consent
Discuss anaesthetic options and present
overview of risks
In a timely fashion if possible
Document the discussion clearly
46. Standardization
Preblock checklist
Use standard technique (institution or
wider) or document why other technique
used
Build a common approach across the
surgical team using agreed outcomes
Follow up carefully
53. Existing Techniques to
Reduce Complications:
Judicious sedation
Nerve stimulation
Epinephrine
Negative aspiration
Slow, incremental injection
Safer local anesthetics
Good training
Newer techniques
Injection pressure
Ultrasound
Tissue impedance
54. “Our masters at NICE
have all spoken
This Scanner is not just a
token
To look with one eye
Is better then try
And end up with carotids
all broken”
Alastair Waite FRCA
Edinburgh 2004
55. Balancing Benefits and Risks
1. Get trained
2. Clear and documented informed consent
3. Team approach
4. Use your senses: Blood on aspiration, tissue
expansion (US), minimize pressure, nerve
expansion (US), slow, incremental injection
5. Beware low stimulation currents, pain on
injection, tachycardia
6. Follow up carefully
56. Summary
Regional anaesthesia provides significant
benefits for our patients
Risks are low but present
A pragmatic approach that balances
benefit and risk is needed
Clear explanation and documentation of
informed consent is important
Regional anaesthesia is technically
demanding, beneficial and very satisfying
57. “Gentleness is the first requisite
of the anesthetist. He should
handle his patient and needle
with equal dexterity”
Gaston Labat 1922