R a for high risk patients
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R.A. for high-risk patients. Olivier Choquet Department of Anesthesiology and Critical Care Medicine Lapeyronie University Hospital Montpellier, France. DISCLOSURE. The high risk patient Menu. The risk of complication Surgery - Anesthesia - Pulmonary - Cardiac

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R a for high risk patients

R.A. for high-risk patients

Olivier Choquet

Department of Anesthesiology

and

Critical Care MedicineLapeyronie University Hospital Montpellier, France


Disclosure

DISCLOSURE


The high risk patient menu

The high risk patientMenu

  • The riskof complication

    • Surgery - Anesthesia - Pulmonary - Cardiac

  • The Risk of Medical liability

    • Anesthesist - GA - RA

  • The stratagem

  • Think different !

  • Conclusion


H igh risk patient for surgery intraoperative predictors

High risk patient for surgeryIntraoperative predictors

Site of Surgery

Thoracic and upper abdominal

2-3 X’s risk of extremity procedures

Duration > 3 hours

↑ risk of morbidity & mortality

Emergency Surgery

2 - 5 X’s greater risk than non-emergent surgery


High r isk patient for g a difficult airway full stomach

High Risk patient for G.A.difficultairway – full stomach…

  • Obese – pediatriclymphoma – obstetrics…

  • :


Risk of severe complications after ga

Risk of severe complications after GA

Occasional anaesthetic catastrophes 1:250 000

Death - Hypoxic brain damage

Approx. 1% risks

Adverse drug reactions - malignant hyperpyrexia - Aspiration pneumonitis - Anaphylaxis to anaesthetic agents - Cardiovascular collapse - Respiratory depression -Nerve injury - Damage to the eyes - Awareness during anaesthesia - Damage to teeth- Sore throat - laryngeal damage

Severe complications are uncommon

Not discussed with patients !

Are these reduced by regional Anaesthesia ?


High risk patient for r a

High risk patient for R.A

  • Uncooperative patient

  • Neurological deficit

  • Bleeding disorder

  • Anatomical deformity

  • Complicated surgeries that involved

    • Prolonged operation - Several / large body parts

    • major blood loss

    • maneuvers that compromise respiration


Risk of severe complications after ra

Risk of severe complications after RA

Cardiac arrest after spinal A5:10.000

  • Systemic toxicity5:10.000

    Transient neuropathy after

    spinal / epidural anesthesia 2-4:10.000

    PNB100:10.000

    Permanent neurological injury after

    spinal / epidural anesthesia 0-4:10.000

    PNB0-1:10.000

  • Death – brain damage0-1:100.000

  • AuroyAnesthesiology 2002

Severe complications are uncommon


Pulmonary risk easy

Pulmonary risk: easy !

  • If possible,

  • prefera regional


Cardiac risk general vs regional

Cardiac riskGeneral vs. Regional

  • ADVANTAGESof regional in the cardiac pt.

    • Less myocardial, respiratory depression

    • Avoid endotracheal intubation (autonomic stimulation)

  • DISADVANTAGESof regional in the cardiac pt.

    • Anxiety catecholamine release MVO2

    • Spinal vasodilation BP

  • Benefits of neuraxial anesthesia and analgesia

  • Less blood loss

  • Superior pain control

  • Decreased ileus

  • Fewer pulmonary complications


Cardiac risk general vs regional1

Cardiac riskGeneral vs. Regional

  • The choice of anaesthesia does not affect cardiac morbidity and mortality

  • No fewer thromboembolic events when DVT prophylaxis used

    Nishina K et al. Anesthesiology 2002; 96: 323.

    Park WY et al. Ann Surg 2001; 234: 560

    Peyton PJ et al. AnesthAnalg 2003; 96: 548.

    Rigg JRA et al. Lancet 2002; 359: 1276.

    Ballantyne J clinanesth 2005, 35: 382

  • Factors other than type of anaesthesia are more important for cardiac outcome in high-risk patients

    Zaugg M et al. Br J Anaesth 2004; 93:53


Cardiac risk more difficult stratification clinical factors

Cardiac risk: more difficult !stratification: clinical factors

  • ASA Class - Functional status – Age

  • Ischemic heart disease - heart Failure

  • Cerebrovascular disease

  • Significant arrhythmias

  • Severe valvulardisease

  • Diabetes - Renal insufficiency

  • Type of surgery

  • Gupka circulation 2011 – Lidenauer NEJM 2005


Cardiac risk stratification surgical factors

Cardiac riskstratification: Surgical factors

  • High risk: > 5% of cardiac event (fatal and non-fatal MI)

    • Emergent major operations, esp. in elderly

    • Anticipated large fluid shifts and/or blood loss

    • Aortic/ major vascular surgery

    • Peripheral vascular surgery

  • Intermediate risk: < 5% risk of event

    • Carotid endarterectomy

    • Head and neck surgery

    • Intraperitoneal and intrathoracic surgery

    • Orthopedic or Prostate surgery

  • Low risk: < 1% risk of cardiac event)

    • Endoscopic - Superficial procedures

    • Cataract - Breast surgery


R a for high risk patients

No data concerning PNB …


The high risk patient menu1

The high risk patientMenu

  • The riskof complication

    • Surgery - Anesthesia - Pulmonary - Cardiac

  • The Risk of Medical liability

    • Anesthesist - GA - RA

  • The stratagem

  • Think different !

  • Conclusion


Complications are rare but highlighted what is the risk of claim

Complications are rare but highlightedwhat is the risk of claim?

  • G.A versus Neuraxial A. versus PNB ?


What is the risk of claim after ra ga

What is the Risk of claim after RA / GA ?

The ASA Closed Claims Project

4.723 closed malpractice claims - 14.500 anesthesiologists

  • 67% (3.180) of the claims are associated with general anesthesia and 24%(1.133) are associated with the use of regional anesthesia.RA : one out of five

    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 RA: Less severe

    Cheney, FW: High-Severity Injuries Associated with Regional Anesthesia in the 1990s. ASA Newsletter 65(6): 6-8, 2001


Trends in damaging events anesthesia

Trends in Damaging Events: Anesthesia

  • The winner is: Respiratory and Cardiovascular Events

    • Primary events leading to death and brain damage

      • In the 1990’s respiratory and cardiovascular events about equal

    • Respiratory events have declined substantially

      • Oximetry and end-tidal CO2 monitors became ASA standard in early 1990’s

      • Difficult Airway Guidelines introduced in 1993.

    • Cardiovascular events increasing – no significant pattern emerges.

      • Injuries related to bradycardia and hypotension

      • Largest cardiovascular related category of events causing death or brain damage is “unexplained other” Includes pulmonary embolism, stroke, MI, arrhythmia and undiagnosed preop conditions such as cardiomyopathy

        Cheney, FW: Changing Trends in Anesthesia-Related Death and Permanent Brain Damage ASA Newsletter

        66(6): 6-8, 2002.


R a for high risk patients

adverse anesthetic outcomes collected from closed anesthesia malpractice insurance claims

35 professional liability companies

About 5000 claims

3000 other claims80 %

1000 regional anesthesia claims 20 %

800 neuraxialblockade 16%

200 PNB (& eye blocks)4%

20 years - USA


Trends in damaging events ra

Trends in Damaging Events: RA

  • Major factors in poor outcome

    • Neuraxial cardiac arrest / Sympathetic blockade

    • Neuraxial hematoma / coagulopathy

    • Eye blocks associated with sedation

    • Local anesthetic toxicity

  • PNB-related High-severity injuries consisted primarily of nerve damage and local anesthetictoxicity

  • Most PNB claims associated with temporary injuries


Cost of litigation ra ga

Cost of litigation: RA < GA


The classical alternative spinal vs general

According to the ASA Closed Claims Reviews, airway adverse events still represent the greatest cause of liability and the largest awards owing to malpractice.

The classical alternative: spinal vs general

If possible, don’t manipulate the airway

DH. Lambert, PhD, MD

Boston University School of Medicine 2006


R a for high risk patients

Number of claims (1999-2009)

GAMM insurancecompagnyIn France

10 years - 2500 claims - 1500 Anesthetists

1500GA 75%

400Post op15%

50Position 5%

300RA11%

100spinal 3 %

  • 100epidural 3 %

  • 100PNB 3 %


R a for high risk patients

419

No deathrelated to PNB


Root causes specific to general anesthesia complications

Root causes specific to general anesthesia complications


The high risk patient menu2

The high risk patientMenu

  • The riskof complication

    • Surgery - Anesthesia - Pulmonary - Cardiac

  • The Risk of Medical liability

    • Anesthesist - GA - RA

  • The stratagem

  • Think different !

  • Conclusion


Risk based on the activity

Riskbased on the activity

Amateur system

artistic

Hihtsafe system

Bank controlled

Safe system

controlled…

No infaillible system

known to dateist…

Medicine

Hymalaya

climber

nuclear

car

railway

airplane

One disasterout of 1 000 000

One disasterout of 100

One disasterout of 1 000

One disasterout of 10 000

One disasterout of 100 000


Risk general anesthetia

Risk: General Anesthetia

Amateur system

artistic

Hihtsafe system

Bank controlled

Safe system

controlled…

Blood transfusion

Risque anesthésique

No infaillible system

known to dateist…

Cardiacsurgery

patient ASA 3-4

General surgery

patient ASA 1 2

Medicine

Hymalaya

climber

nuclear

car

railway

airplane

One disasterout of 1 000 000

One disasterout of 100

One disasterout of 1 000

One disasterout of 10 000

One disasterout of 100 000


Risk regional anesthetia

Risk: RegionalAnesthetia

Amateur system

artistic

Hihtsafe system

Bank controlled

Safe system

controlled…

Transientneuropathy

ISB axBFB

Permanent

neuropathy

PNB

Seizure

Toxsyst

Braindamage SystTox

No infaillible system

known to dateist…

epidural

obstetrics

spinal

orthopedics

Cardiacarrest / spinal

Paraplegia / epidural

Cardiacsurgery

patient ASA 3-4

General surgery

patient ASA 1 2

Medicine

Hymalaya

climber

nuclear

car

railway

airplane

One disasterout of 1 000 000

One disasterout of 100

One disasterout of 1 000

One disasterout of 10 000

One disasterout of 100 000


High risk patient general

High risk patient: general

Amateur system

artistic

Hihtsafe system

Bank controlled

Safe system

controlled…

>80ans

ASA 3

Heartfailure

Coronaropathy

Emergency

SAOS

….

AG

No infaillible system

known to dateist…

Medicine

Hymalaya

climber

nuclear

car

railway

airplane

One disasterout of 1 000 000

One disasterout of 100

One disasterout of 1 000

One disasterout of 10 000

One disasterout of 100 000


High risk patient spinal

High risk patient: spinal

Amateur system

artistic

Hihtsafe system

Bank controlled

Safe system

controlled…

>80ans

ASA 3

Heartfailure

Coronaropathy

Emergency

SAOS

….

AG

No infaillible system

known to dateist…

Medicine

Hymalaya

climber

nuclear

car

railway

airplane

One disasterout of 1 000 000

One disasterout of 100

One disasterout of 1 000

One disasterout of 10 000

One disasterout of 100 000


High risk patient pnb

High risk patient: PNB

Amateur system

artistic

Hihtsafe system

Bank controlled

Safe system

controlled…

>80ans

ASA 3

Heartfailure

Coronaropathy

Emergency

SAOS

….

AG

No infaillible system

known to dateist…

Medicine

Hymalaya

climber

nuclear

car

railway

airplane

One disasterout of 1 000 000

One disasterout of 100

One disasterout of 1 000

One disasterout of 10 000

One disasterout of 100 000


The high risk patient

The high risk patient

  • Plan Aplan BPlan C

Benefit/ risks / stratification

The choice


The high risk patient menu3

The high risk patientMenu

  • The riskof complication

    • Surgery - Anesthesia - Pulmonary - Cardiac

  • The Risk of Medical liability

    • Anesthesist - GA - RA

  • The stratagem

  • Think different !

  • Conclusion


Change your mind concerning r a

change your mind concerning R.A.

  • The use of R.A. is subject to the same risk-benefit analysis that applies to any anesthetic technique.

  • Michael F. Mulroy in the 1990's

  • Medical liability weight:

  • GA > neuraxial A > PNB ?

  • Progress in regional anesthesia

  • Most classical contraindications of R.A.

  • become today

  • Absolute indications in many high risk patients


C ontra indications absolute relative

Contra-indications ??? Absolute  relative

  • Risk of local anesthetic toxicity

    • Dilute L.A. - fractioned dose - lesser volume (US) - delay

  • Systemic infection

    • RA performed if systemic antibiotic therapyinstituted

  • Infection at the injection site

    • RA Performed in healthy area (supraclavicular…) !

  • True Allergy to L.A.

    • Ensure that it is a “true” allergy


  • Patient refusal an absolute contraindication

    Patient refusal an absolute contraindication ?

    • If regional techniques offer significant advantages in risk reduction in a specific situation, these need to be discussed with the patient and the surgeon.

    • If the patient still refuses, other alternatives should be considered.

    No; if i don'tperform a GA

    May I die, doctor


    Be persuasive

    Be persuasive !

    • Because safety >>> comfort

    • Riskbenefit ratio : Explain – Refute!!


    Argue for moderate sedation

    Argue for moderate sedation !

    • Doctor: "You prefer to sleep with or without an endotracheal tube !" …

    • Patient: "a what ! … Without ! "…

    • Doctor: "Perfect, it's called a sedation"

    Patient remains: Anxiety & pain free ; Arousable, but relaxed; Cooperative on demand; With Intact protective reflexes; spontaneous ventilation; cardiovascular stability


    Absolute c ontraindications to neuraxial potential indication to pnb

    Absolute Contraindicationsto neuraxial potential indication to PNB

    • Bleeding disorder: partial anticoagulation – clopridogel

      • superficial PNB

    • Hypovolemia

    • Increased Intracranial pressure

    • Severe Aortic Stenosis - Mitral Stenosis

    • Severe spinal deformities

    • Prior back surgery


    Pnb in high risk patients

    PNB in high risk patients


    R a for high risk patients

    • Combined lumbar and sacral plexus Block

    • Secured under ultrasound guidance

    • Appropriate conditions for surgery, hemodynamic stability, and postoperative analgesia


    Root causes specific to regional anaesthesia complications

    Root causes specific to regional anaesthesia complications

    • High doses of L.A.

    • Insufficientphysicianexperience

    • Excessive (uncontrolled) sedation

    • “less than gentle” RA technique

    • Inadequate or perilousprocedures

    • No “back up” plan been made in the event of a failure of the RA technique


    Conclusions in high risk patients

    Conclusions : in High-risk patients

    • PNB > neuraxial A. > G.A. in several cases

    • Risk Benefit Assessment is the cornerstone

    • Informed consent need to be obtained

    • Safety > comfort

    • RA often appropriate

    • but must be carried out perfectly !


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