Is Regional Anesthesia Safer for My Patient?

1. 2nd Annual Ellison Pierce Symposium Positioning Your ORs For The Future Is Regional Anesthesia Safer for My Patient? Donald H. Lambert, PhD, MD Boston University School of Medicine May 19, 2006 2:00-2:30pm

2. In your opinion, how much safer do you think regional anesthesia is compared to general anesthesia? QUESTION: • Much safer • Safer in most situations • Safer in some situations • Not safer 0 / 10

3. What is the most common adverse outcome of anesthesia? QUESTION: • Airway trauma • Nerve damage • Brain damage • Death 0 / 10

4. Overview • Mr. D***** • Disclosure • Background • Putative Advantages of Regional Anesthesia • Why Isn’t 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 Don’t We Do More Regional Anesthesia at This Institution • Keeping It Simple and Keeping It Safe

5. 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?

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

7. 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 Women’s Hospital who believe that regional anesthesia is better than general anesthesia

8. 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”)

9. 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.

10. Why Isn’t 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.

11. Why Isn’t 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

12. Why Isn’t 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

13. Why Isn’t There Evidence for theSuperiority of Regional Over General Why should an anesthetic which provides only hours at most of a patient’s total hospitalization alter morbidity and/or mortality anyway?

14. 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

15. 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?

16. We can learn from other’s mistakes Air SafetyFoundationAnnual Reports(like the APSF and the Closed Claims database)

17. The ASA Closed Claims Project

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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 Project:Lessons Learned. ASA Refresher Course Lectures 2004; 118

26. The ASA Closed Claims Project Caplan RA. The ASA Closed Claims Project:Lessons Learned. ASA Refresher Course Lectures 2004; 118

27. 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

28. 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

29. 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

30. 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 don’t have to?

31. 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

32. The Obstetrical Experience

33. Why don’t 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 surgeon’s cooperation is essential.

34. Dr. Susan Steele Steele SM Practical Regional Anesthesia for Outpatients ASA Refresher Course Lectures 2004, 226

35. Why don’t 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

36. And Above All...

37. It’sEasier Than...

39. Mr. D***** Remember Mr. D*****?

40. Mr. D***** • Got a 10 mg bupivacaine spinal • Did not get a Swan • Went to the PACU and then to the floor

41. 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?

42. Thank You and Fly Safely