Is Regional Anesthesia Safer for My Patient?

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Is Regional Anesthesia Safer for My Patient?
2nd Annual Ellison Pierce Symposium Positioning
Your ORs For The Future

• Donald H. Lambert, PhD, MD

Boston University School of Medicine May 19, 2006
200-230pm
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In your opinion, how much safer do you think
regional anesthesia is compared to general
anesthesia?
QUESTION

1. Much safer
2. Safer in most situations
3. Safer in some situations
4. Not safer

0 / 10
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What is the most common adverse outcome of
anesthesia?
QUESTION

1. Airway trauma
2. Nerve damage
3. Brain damage
4. Death

0 / 10
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Overview

• Mr. D
• Disclosure
• Background
• Putative Advantages of Regional Anesthesia
• Why Isnt There Evidence for the Superiority of
  Regional Over General
• Building a Case for the Safety of Regional
  Anesthesia
• The ASA Closed Claims Project
• The Success of Obstetric Anesthesia
• Why Dont We Do More Regional Anesthesia at This
  Institution
• Keeping It Simple and Keeping It Safe

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Mr. D

• 90 year old man for repair of fractured hip
• 10 ejection fraction!
• Multiple other co-morbidity
• Medical consult Swan Ganz monitoring, avoid
  hypoxemia and hypotension, ICU postoperatively
• Who in this audience would do general anesthesia?
• Who in this audience would do regional
  anesthesia? What kind?

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Disclosure
I am partial to and biased in favor of regional
anesthesia.
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Some Background

• Life without a recovery room (aka PACU) at UVM
• Life in the shadow of giants
• Halcion days with Ben Covino, Alon Winnie, D.
  Bruce Scott, and others at the Brigham and
  Womens Hospital who believe that regional
  anesthesia is better than general anesthesia

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Putative Advantages ofRegional Anesthesia

• Decreased adverse metabolic and endocrine effects
  (stress response) of surgery
• Decreased blood loss and transfusion requirements
• Decreased pulmonary complications
• Decreased incidence of thromboembolism
• Decreased postoperative ileus
• Decreased mortality
• Decreased post-operative pain (preemptive
  analgesia, less windup)

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More Putative Advantages ofRegional Anesthesia

• Less confusion and delirium in the elderly
• Shorter hospital stay resulting in decreased cost
• Less nausea and vomiting
• Increased patient satisfaction
• Less complicated than general anesthesia
• Easier in some cases (spinal for LE operations v.
  general)
• Etc.

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Why Isnt There Evidence for theSuperiority of
Regional Over General

• Both regional and general anesthesia are very
  safe.
• Randomized double blinded studies may not be
  powerful enough to show a difference between
  regional and general.

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Why Isnt There Evidence for theSuperiority of
Regional Over General

• There is one meta-analysis of spinal/epidural vs.
  general that found a difference in the following
  morbidity and mortality
• 141 trials including 9559 patients
• Overall mortality was reduced by about a third in
  patients allocated to neuraxial blockade (103
  deaths/4871 patients versus 144/4688 patients)
• Neuraxial blockade reduced the odds of DVT by
  44, PE by 55, transfusions by 50, pneumonia
  by 9, and respiratory depression by 59

Rodgers A, et al Reduction of postoperative
mortality and morbidity with epidural or spinal
anaesthesia results from overview of randomized
trials. BMJ 2000 321 1493
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Why Isnt There Evidence for theSuperiority of
Regional Over General

• There is one meta-analysis of spinal/epidural vs.
  general that found a difference in the following
  morbidity and mortality
• CONCLUSIONS Neuraxial blockade reduces
  postoperative mortality and other serious
  complications
• The size of some of these benefits remains
  uncertain, and further research is required to
  determine whether these effects are due solely to
  benefits of neuraxial blockade or partly to
  avoidance of general anesthesia

Rodgers A, et al Reduction of postoperative
mortality and morbidity with epidural or spinal
anaesthesia results from overview of randomized
trials. BMJ 2000 321 1493
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Why Isnt There Evidence for theSuperiority of
Regional Over General
Why should an anesthetic which provides only
hours at most of a patients total
hospitalization alter morbidity and/or mortality
anyway?
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Building a Case for the Safety of Regional
Anesthesia

• The ASA Closed Claims Project
• Possibly fewer complications
• Complications may be less severe
• Financial awards for complications with
  regional anesthesia may be smaller
• The successes owing to the use of regional
  anesthesia in obstetrics
• It is just easier to do than general anesthesia

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It is better to be on the ground and wishing you
were flying than to be flying and wishing you
were on the ground!
How do we do that?
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We can learn from others mistakes
Air SafetyFoundationAnnual Reports(like the
APSF and the Closed Claims database)
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The ASA Closed Claims Project
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The ASA Closed Claims Project

• Major trends in the Closed Claims Project
  database showed
• Respiratory system events accounted for a large
  share of all claims, and
• An especially large percentage of claims for
  death and brain damage.
• The most common events leading to injury were
• Inadequate ventilation
• Esophageal intubation
• Difficult tracheal intubation.

Cheney FW The American Society of
Anesthesiologists Closed Claims Project what
have we learned, how has it affected practice,
and how will it affect practice in the future?
Anesthesiology 1999 91 552-6
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The ASA Closed Claims Project

• The occurrence of respiratory system events has
  decreased primarily in claims for injuries due
  to
• inadequate ventilation
• esophageal intubation
• Remaining relatively constant however is
• difficult tracheal intubation

Cheney FW The American Society of
Anesthesiologists Closed Claims Project what
have we learned, how has it affected practice,
and how will it affect practice in the future?
Anesthesiology 1999 91 552-6
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The ASA Closed Claims Project

• Although claims for death and brain damage are
  decreasing
• Nerve injury may become the leading cause of
  anesthesia-related injury for which a
  malpractice claim is made.
• In the 1990s, injury to the spinal cord was the
  most frequent claim for nerve damage
• These seem related to injuries from neuraxial
  block in anticoagulated patients and blocks for
  chronic pain management

Cheney FW The American Society of
Anesthesiologists Closed Claims Project what
have we learned, how has it affected practice,
and how will it affect practice in the future?
Anesthesiology 1999 91 552-6
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The ASA Closed Claims Project

• At the time of this analysis, the ASA Closed
  Claims Project database consisted of 4,723
  closed malpractice claims retrieved from 35
  insurance organizations that insured
  approximately 14,500 anesthesiologists
• Of the total database, 67 (3,180) of the claims
  are associated with general anesthesia and
  24 (1,133) are associated with the use of
  regional anesthesia.

Cheney, FW High-Severity Injuries Associated
with Regional Anesthesia in the 1990s. ASA
Newsletter 65(6) 6-8, 2001
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The ASA Closed Claims Project
Death is more common among the claims involving
general anesthesia, while permanent-disabling and
nondisabling temporary injuries are present in a
higher proportion of claims associated with
regional anesthesia.
Cheney, FW High-Severity Injuries Associated
with Regional Anesthesia in the 1990s. ASA
Newsletter 65(6) 6-8, 2001
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The ASA Closed Claims Project

• Of claims where the injuries occurred in the
  1990s, death occurred in 25 of those associated
  with general anesthesia and 10 of those
  associated with regional anesthesia.
• Focusing on claims where the injury occurred in
  the 1990s, claims associated with regional
  anesthesia are more likely to be of a lower
  severity than those associated with general
  anesthesia

Cheney, FW High-Severity Injuries Associated
with Regional Anesthesia in the 1990s. ASA
Newsletter 65(6) 6-8, 2001
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The ASA Closed Claims Project
While high-severity, anesthesia-related injuries
are more common with general anesthesia than
regional anesthesia, the lack of denominator data
in the Closed Claims Project does not allow any
conclusions to be drawn about the safety of
either technique.
Cheney, FW High-Severity Injuries Associated
with Regional Anesthesia in the 1990s. ASA
Newsletter 65(6) 6-8, 2001
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The ASA Closed Claims Project
In the decade of the 1970's, adverse respiratory
events accounted for 55 of all claims for death
or brain damage, compared to 50 in the 1980's,
and 45 in the 1990's
Caplan RA. The ASA Closed Claims ProjectLessons
Learned. ASA Refresher Course Lectures 2004 118
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The ASA Closed Claims Project
Caplan RA. The ASA Closed Claims ProjectLessons
Learned. ASA Refresher Course Lectures 2004 118
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Airway, Airway, Airway!

• Difficult airway claims arose throughout the
  perioperative period
• induction - 67
• during surgery - 15
• at extubation - 12,
• during recovery - 5
• Death and brain damage with induction of
  anesthesia decreased
• 1985-1992 (62)
• 1993-1999 (35)
• In contrast, death or brain damage associated
  with other phases of anesthesia did not
  significantly change over these time periods

Peterson GN, et al Management of the difficult
airway a closed claims analysis. Anesthesiology
2005 103 33-9
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The ASA Closed Claims Project
Respiratory system adverse events represent the
most common mechanism leading to anesthesia
malpractice claims, accounting for a large
proportion of claims for death and brain damage
in the American Society of Anesthesiologists
(ASA) Closed Claims database.
Peterson GN, et al Management of the difficult
airway a closed claims analysis. Anesthesiology
2005 103 33-9
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The ASA Closed Claims Project But, there is no
such thing as a free lunch

• Although claims for death and brain damage are
  decreasing
• Nerve injury may become the leading cause of
  anesthesia-related injury for which a malpractice
  claim is made.
• In the 1990s, injury to the spinal cord was the
  most requent claim for nerve damage
• These seem related to injuries from neuraxial
  block in anticoagulated patients and blocks for
  chronic pain management

Cheney FW The American Society of
Anesthesiologists Closed Claims Project what
have we learned, how has it affected practice,
and how will it affect practice in the future?
Anesthesiology 1999 91 552-6
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Airway, Airway, Airway!
A philosophy According to the ASA Closed Claims
Reviews, airway adverse events still represent
the greatest cause of liability and the largest
awards owing to malpractice. Should we manipulate
the airway if we dont have to?
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Trends in Complications in OB Claims 1970 vs.
1990s
Davies JM Closed Claims Project Focuses on 3
Decades of Obstetric Complications. APSF
Newsletter 19(4) 49 57
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The Obstetrical Experience
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Why dont we do more Regional Anesthesia at this
institution?

• Good training is required.
• The best thing for doing regional anesthesia is
  doing regional anesthesia (a lot).
• The anesthesiologist must want to do it.
• The culture at the institution has to be
  amenable.
• What works at one institution will just not work
  at another institution.
• The surgeons cooperation is essential.

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Dr. Susan Steele
Steele SM Practical Regional Anesthesia for
Outpatients ASA Refresher Course Lectures 2004,
226
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Why dont we do more Regional Anesthesia at this
institution?

• Surgeon Education
• The acceptance of regional anesthesia techniques
  is enhanced if the surgeons are fully informed
  of the benefits associated with them
• Frequently, the surgeons become so enthusiastic
  about these techniques that they introduce it to
  patients at the clinic
• Surgeons should be aware that multimodal pain
  management improves pain control

Steele SM Practical Regional Anesthesia for
Outpatients ASA Refresher Course Lectures 2004,
226
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And Above All...
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Its Easier Than...
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(No Transcript)
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Mr. D
Remember Mr. D?
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Mr. D

• Got a 10 mg bupivacaine spinal
• Did not get a Swan
• Went to the PACU and then to the floor

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Mr. D

• Could he have been done just as well and with
  the same outcome with general anesthesia?
• Of course.
• Would it have been as simple?
• Would he have done as well?

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Thank You and Fly Safely