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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

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 A 5:10.000

  • Systemic toxicity 5:10.000

Transient neuropathy after

spinal / epidural anesthesia 2-4:10.000

PNB 100:10.000

Permanent neurological injury after

spinal / epidural anesthesia 0-4:10.000

PNB0-1:10.000

  • Death – brain damage 0-1:100.000
  • 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
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.

slide19
adverse anesthetic outcomes collected from closed anesthesia malpractice insurance claims

35 professional liability companies

About 5000 claims

3000 other claims 80 %

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
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

slide24

Number of claims (1999-2009)

GAMM insurancecompagnyIn France

10 years - 2500 claims - 1500 Anesthetists

1500 GA 75%

400 Post op 15%

50Position 5%

300RA 11%

100spinal 3 %

  • 100epidural 3 %
  • 100PNB 3 %
slide25

419

No deathrelated to PNB

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 A plan B Plan 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
slide44
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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