Balancing Risks and Benefits of Regional Anaesthesia
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Transcript of Balancing Risks and Benefits of Regional Anaesthesia
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Colin J.L. McCartney MBChB PhD FCARCSI FRCA FRCPCProfessor and Chair of Anaesthesia and Pain MedicineUniversity of OttawaHead of AnaesthesiaThe Ottawa HospitalScientist, Ottawa Hospital Research InstituteBalancing risk and benefit with regional anaesthesia
1Good morning. My name is Colin McCartney and I am an anesthetist and consultant in chronic pain management from Toronto Western Hospital.
Conflicts of InterestConsultant: Teleflex Medical
SummaryRegional anaesthesia provides significant benefits for our patientsA pragmatic approach that balances benefit and risk is neededClear explanation and documentation of informed consent is important
Benefits of Regional AnaesthesiaBetter 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)
Regional Anesthesia Reduces Pain
Anesthesia & Analgesia 2012
Value of RA on pain
Value of RA on pain
McCartney, Brull et al 2004
Value of RA on adverse events
McCartney, Brull et al 2004
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)
Regional Anaesthesia and Big DataReduction in surgical site infectionReduced critical care utilizationFaster dischargeReduced readmissionReduction in mortality
BMJ 2000
400 hospitals between 2006-10Data from primary hip/knee arthroplastySubgrouped by anesthetic technique30 day morbidity and mortality data
Anesthesiology 2013
382,000 patients25% neuraxialNeuraxial associated with less mortality, length of stay, in-patient morbidity
Anesthesiology 2013
Regional anesthesia Cancer outcomes
Chronic Pain
23 RCTs in totalPooled 3 studies for epidural after thoracotomy and 2 for PVB after breast surgeryUnable to pool data from other studies due to marked heterogeneity
Andreae MH et al BJA 2013
RA and AVF patency
My own experienceEdinburgh and Bruce ScottDundee and Bill MacraeAberdeen and Alistair ChambersToronto and and Vincent ChanMultiple patients over 25 years
Regional Anaesthesia Risks
Look at the big picture
Guardian 11th September 2015
RAPM 2012
RA Risks: Central TechniquesNeuropathy 2-3/10,000Haematoma 12.3/100,000Abscess 73/100,000Paraplegia or Death 0.7-1.8/100,000Brull R et al 2005Cook TM et al 2009Cameron CM et al 2007
RA risks: PNB Seizures (5-20/10,000)Cardiac complicationsPneumothorax (up to 6%)Respiratory failureEye injuries Nerve injury (3-30/10,000)Death (1 case LPB)Auroy Y 2002
Complications: Minor Pain during block performance Painful paresthesiaePost-block bruising/hematomaIntravascular injection (tachycardia/hypertension)
Prevention and Management of RA RisksDocumented informed consentBalance of benefit vs riskStandardization of process and techniqueJust culture and learning from errorGood training and use of effective techniqueDoctor: Patient relationship
Informed ConsentDiscuss anaesthetic options and present overview of risksIn a timely fashion if possibleDocument the discussion clearly
Balance risk vs benefit
Balance risk vs benefit
Standardization
StandardizationPreblock checklistUse standard technique (institution or wider) or document why other technique usedBuild a common approach across the surgical team using agreed outcomesFollow up carefully
Preblock Checklist
www.edmariano.com
Just culture: learning from error
Just Culture and Medical Error
http://www.unmc.edu/patient-safety/_documents/patient-safety-and-the-just-culture.pdf
TrainingLenters et al 2007
Kathy Sierra: http://headrush.typepad.com/creating_passionate_users/2006/03/how_to_be_an_ex.html
Konrad et al Anesth Analg 1998
Existing Techniques to Reduce Complications:Judicious sedationNerve stimulationEpinephrineNegative aspirationSlow, incremental injectionSafer local anestheticsGood trainingNewer techniquesInjection pressureUltrasoundTissue impedance
Our masters at NICE have all spokenThis Scanner is not just a tokenTo look with one eyeIs better then tryAnd end up with carotids all brokenAlastair Waite FRCAEdinburgh 2004
Balancing Benefits and RisksGet trainedClear and documented informed consentTeam approachUse your senses: Blood on aspiration, tissue expansion (US), minimize pressure, nerve expansion (US), slow, incremental injectionBeware low stimulation currents, pain on injection, tachycardiaFollow up carefully
SummaryRegional anaesthesia provides significant benefits for our patientsRisks are low but presentA pragmatic approach that balances benefit and risk is neededClear explanation and documentation of informed consent is importantRegional anaesthesia is technically demanding, beneficial and very satisfying
Gentleness is the first requisite of the anesthetist. He should handle his patient and needle with equal dexterity
Gaston Labat 1922