Regional Anesthesia is Better than General Anesthesia

Regional Anesthesia is Better than
General Anesthesia
Professor of Anesthesiology and Intensive Care
Medicine
Chair and Head of Department
Department of Anesthesia and Intensive Care
Medicine
Lapeyronie University Hospital
Montpellier - France

What should we speak about?
• Regional anesthesia for the peroperative period :
- Quality of Anesthesia
- Quality of postoperative analgesia
- Cost effectiveness
- Adverse events

Pain disorders in the
postoperative period
Scores EVA
7
6
5
4
3
2
1
0
J1 J2 J3 J4 J5 J6 J7 J8
Jours postopératoires
Vial et al. Ann Fr Anesth Réanim 2000

35
30
25
20
15
10
5
0
Pain symptoms at 24h
Pain
Hoarseness
Sore throat
Nausea
Headache
Chung. Anesth Analg 1995;80:896-902
Faintness
% of patients

Some aspects of functional impact of
Ambulatory surgery
D 1 D 2 D 7
Painful patients (n) 80 70 54
Troubles for (%)
Activity level 73 61 50
Walk 69 49 38
Work 81 68 47
Mood 22 23 15
Relational 21 20 9
Sleep 47 34 24
Concentration 38 20 13
Beauregard et al. Can J Anaesth 1998;45:304-11.

Potential Benefits of RA vs GA in Day Surgery
Advantages to patients
Improved quality of recovery
less postoperative pain
less postoperative nausea and vomiting
•able to observe the procedure
•communication with surgeon during procedure
•an option to receive no, light or heavy sedation
•earlier mobilisation
Advantages to Surgeon and staff
assessment of function before wound closure
possible to discuss treatment options with patient
"fast tracking", i.e. by-passing phase I recovery room
shortened recovery time
less requirements in PACU/Phase II recovery room
fewer unanticipated overnight admissions

Strategies for success with RA in Day Surgery
surgeon should discuss with initial patient visit that RA is an option
assessment at preanaesthesia clinic
discuss benefits of RA
discuss different options for sedation/MAC*
discuss treatment of possible pain after the block wears off
printed information for patients
instructional videos helpful
rediscussion of RA on the day of operation
anaesthesiologist should be interested and skilled with blocks they are us
MAC = monitored anaesthesia care

Optimising spinal anaesthesia for Day Surgery.*
bupivacaine 7.5 mg usually appropriate
small doses are not long acting
concentration is related to duration and recovery
hyperbaric bupivacaine slower acting than hypobaric
adrenaline (epinephrine) not recommended
prolongs recovery
intrathecal fentanyl recommended
prolongs anaesthesia but not recovery

Small-dose selective spinal anesthesia for short-duration outpatient laparoscopy :
recovery characteristics
P Lennox Anesth Analg 2002 Spinal : lidocaine 1% 10 mg +10µg sufentanil vs GA :
Desflurane
60
50
Spinal
Desflurane
% of
patients
40
30
Minutes
20
10
0
Extubation
Straight leg raise
Ambulate
Postoperative pain

Small-dose selective spinal anesthesia for short-duration outpatient laparoscopy :
Pharmacoeconomic comparison
Spinal : lidocaine 1% 10 mg +10µg sufentanil vs GA : Desflurane
P Lennox Anesth Analg 2002
120
$ Can
100
Spinal
Desflurane
80
60
40
20
0
Anesthesia supplies
Drugs
Nursing time
Total

Outpatient Orthopedic Procedures
60
50
40
30
% of patients with
significant pain
H24
Day 7
Klein Anesth Analg 2002
Grant Reg Anest Pain Med 2001
Chung Anesth Analg 1997
Chung Can J Anaesth 1996
20
10
0
Sciatic Block
Fe m oral Block
Lumbar Ple xus
Sciatic Block
Fe m oral Block
Lumbar Ple xus
Some RA
Without RA

Use of different RA techniques for Day Surgery in USA
Technique
% of DSU using this block
IVRA 80
Axillary block 75
Spinal
72
Epidural 64
Ankle block 55
Interscalene 42
Intercostal block 29
Femoral block 19
Elbow block 18
Sciatic block 12
Popliteal 8

Why are the anesthetists not agree with the regional
anesthesia techniques?
Unfamiliarity with the techniques
No advantage to the technique over standard methods
Surgical preference
Toxicity of the local anesthetic
Unfamiliarity with the techniques
Inability for patients to care for themselves
Patient injury (i.e. fall, accidental limb or nerve trauma)
Preparation time/logistics
Onset time
Percent
0 10 20 30 40 50 60
S. Klein et al. A&A 2002

End of regional block
Is it really a problem?
3
2,5
2
Hospital
At home day 0
t home day 1
*
*
*
1,5
1
0,5
0
No RA Caudal block Infiltration Ilioinguinal
block
Kokinsky et al. Paediatric Anaesthesia 1999

Outpatient Orthopedic Procedures
Arthroscopic ACL Repair Mulroy Reg Anesth Pain Med 2001
45
VAS
Sham Block
40
0.25% Bupi
35
0.5% Bupi
30
25
20
15
10
5
0

Wang Reg Anesth Pain Med
2002
Total knee arthroplasties
30 patients
Hospital stay :
• 3 days with FNB
• 4 days with
Saline

Femoral-sciatic nerve blocks for complex
outpatient knee surgery…
Williams BA et al, Anesthesiology 2003,98:1206-13
Less invasive surgery
• Evaluation during
anesthesia/manipulation
• Knee arthroscopy with
–Debridement
–Lateral retinacular release
–Meniscal surgery/repair
–Removal of superfical hardware
–Allograft ACL reconstruction
More complex surgery
• High tibial osteotomy
• Knee arthroscopy with
–ACL with patellar tendon or
hamstring autograft
–ACL and/or ligament
reconstruction
–Meniscal reconstruction

Femoral-sciatic nerve blocks for complex
outpatient knee surgery…
Williams BA et al, Anesthesiology 2003,98:1206-13
40
30
Percent of patients
No FNB
FNB/FSNB
20
10
0
less
invasive
more
invasive
less
invasive
more
invasive
less
invasive
more
invasive
Pain in PACU Pain in SDRU UHA

A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist
day-case surgeries
A Hadzic Anesthesiology 2004 40 mL of 2-chloroprocaine + propofol sedation vs propofolfentanyl
GA Min
90
80
70
Infraclavicular block
GA
60
50
40
30
20
10
0
OR time
Induction time
Preparation
Surgery

A comparison of infraclavicular nerve block versus general anesthesia for hand and wrist
day-case surgeries
A Hadzic Anesthesiology 2004 40 mL of 2-chloroprocaine + propofol sedation vs propofolfentanyl
250GA
Infraclavicular block
GA
200
Minutess
150
100
% of patients
50
0
Fluid intake
Solid Intake
Ambulatio
Home readiness
Discharge
No pain at 72 h
No medication at 72 h

Fast-tracking after outpatient laparoscopy : reasons for failure after propofol, sevoflurane
and desflurane anesthesia
M Coloma Anesth Analg 2001 Reasons patients did not bypass the postanesthetic
care unit
60
Propofol Sevoflurane Desflurane
50
40
30
20
10
0
Residual sedation Non Specific factors surgical complication no bed available

Process Analysis in Outpatient Knee Surgery : Effects of regional and general
anesthesia on anesthesia-controlled
Cruciate ligament
time
repair , induction rooms , one
B Williams Anesthesiology 2000 anesthetist and two nurses
Parameter
GA
GA/RA
RA
Holding
area time
39 min
33 min
37 min
Anesthesi
a
preparatio
Discharge ntime
time
Nursing
interventio
Incidence ns
of pain
11 min
246 min
2.4
63%*
16 min
238 min
1
23%
17 min*
234 min
0.4*
14%
Incidence
of PONV
39%*
34%
9%

Economics of nerve block pain management after anterior cruciate ligament repair :
Potential hospital cost savings via associated postanesthesia care unit bypass and
same day discharge
B Williams Anesthesiology 2004
100
90
80
70
60
GA without NB
GA with NB
Neuraxial without NB
Neuraxial with NB
lower extremity NB
Scenario
Traditional
care GA
Nerve block
Scenario
PACU costs
105000
18900
Hospital
admission
costs
16363
3850
Total costs
996363
897750
50
Saving with
nerve block
86100
12513
98613
40
30
20
10
0
PACU
bypassed
Nurse Int for
pain
Nurse int for
PONV
Admission
preapproved
Admission
unplanned

Comparison of the costs and recovery profiles of three anesthetic techniques for
ambulatory anorectal surgery
S Li Anesthesiology 2000
Intraoperative
costs
70
Recovery costs
60
Local anesthesia
with sedation
Local
Spinal
GA
63±21
5±2
Spinal
anesthesia
83±15
21±9
General
Anesthesia
125±21
19±9
Perioperative 50
costs
40
Duration of
anesthesia
30
Time to oral
intake 20
69±20
40±15
12±5
103±19
72±17
59±18
145±25
75±19
60±30
Time to Aldrete
10
score of 10
0
19±7
30±19
Time to 0home-
readiness
76±17
193±112
Hypotension Pain Nausea Highly satisfied Satisfied
171±58
Duration of
hospital stay
116±21
266±112
247±65

Global costs for ambulatory orthopedic surgical procedures
Macaire Miner Anesth 2002
Hallux valgus
Classical
RA±GA
Ambulatory +
nurse network
Decrease of
costs
CHU Montpellier 2133 € 484 + 108 € 72 %
Clinique Lyon 1352 € 635 + 108 € 45 %
Rotator cuff
repair
CHU Montpellier 2841 € 1426 +103 € 46 %
Clinique Lyon 1352 € 1052 + 150 € 15 %

Continuous peripheral nerve blocks
- Comparison of costs versus GA.
• Regional anesthesia doesn’t have influence on the duration of the surgical
procedureand doesn’t increase the duration of operating room and PACU
patient’s stay Dexter Reg Anesth Pain Med 1998, Anesth Analg 1995
• For an ambulatory surgery the hospital stay is two times longer with a GA
than with an Axillary Allen Anesthesiology 1993
• Continuous peripheral nerve blocks decrease the overall costs for upper
limb surgery ( 4780 vs 3546 $) , hospital stay and complications Horn
Anesthesiology 2000,2001,2002
•For lower limb procedures , peripheral nerve blocks decrease the global
costs , the amount of patients readmissions and increase the surgical
success Nakamura Arthroscopy 1997, Mulroy Reg Anesth Pain Med 2001,Williams
Anesthesiology 2003

Study WMD Weight 95% CI
Rademaker 94 10,4
Pasqualucci 94 8,9
Joris 95 9,1
Raetzell 95 5,5
Scheinin 95 11,1
Pasqualucci 96 11
Szem 96 11,5
Furher 96 11,3
Mraovic 97 10,5
Tsimoyiannis 98 10,7
Total (95%CI) 100 -13[-20;-6]
Intraperitoneal LA for
cholecystectomy
vs control
Moiniche et al. A&A 2000

Mesosalpinx / fallopian tube block vs control
Moiniche et al. A&A 2000
Study WMD Poids 95% CI
Alexander 87 18,5
Baram 90 10,7
Smith 91 15
Barclay 94 9,2
Wheatley 94 19,5
Ezek 95 12,8
Fiddes 96 14,3
Total (95%CI) 100 -19[-25;-14]

Study WMD Weight 95% CI
Smith 91 15
Hendersen 90 10,6
Smith 92 8,3
Joshi 93 2,8
Richmond 94 3,9
Moiniche et al.
Karlsson 95 8,6
Systematic review
Boden 94 6,7
Intra-articular LA
Björsson 94 3,9 Reg Anesth 1999
Chan 95 7,6
Shaw 95 9,2
Cepeda 97 15
Richardson 97 8,4
Total 100 -10,5 [-13,8;-7,3]

What are really the
reasons for not
using RA ?
Unqualified!!