PowerPoint Presentation
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
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