This document discusses the benefits and risks of regional anesthesia. It notes that regional anesthesia provides significant benefits for patients such as better pain control, reduced complications, and faster recovery. However, risks are also present though low. The document emphasizes taking a pragmatic approach that balances the benefits and risks for each individual patient. It also stresses the importance of clear explanation and documentation of informed consent. Proper training, use of standardized techniques, and a focus on patient safety are recommended to maximize benefits and minimize risks.

1. Colin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of Anaesthesia
and Pain Medicine
University of Ottawa
Head of Anaesthesia
The Ottawa Hospital
Scientist,
Ottawa Hospital Research Institute
Balancing risk and benefit
with regional anaesthesia

2. Conflicts of Interest
 Consultant: Teleflex Medical

4. Summary
 Regional anaesthesia provides significant
benefits for our patients
 A pragmatic approach that balances
benefit and risk is needed
 Clear explanation and documentation of
informed consent is important

5. Benefits of Regional Anaesthesia
 Better pain control (Rigg et al 2002, Park et al 2001)
 Improved quality of life and exercise
tolerance (Carli et al 2002)
 Reduction in respiratory complications
(Ballantyne et al 1998)
 Faster return of GI function (Steinbrook RA 1998)
 Improved tissue oxygenation (Buggy et al 2004)
 Faster discharge (McCartney et al Anesthesiology 2004)
 Less PONV (Chan VW et al 2001)
 Less chronic pain (Katz et al 1994)
 Improved morbidity and mortality (Memtsoudis 2012,
Pugely 2013)

6. Regional Anesthesia
Reduces Pain
Anesthesia & Analgesia 2012

7. Value of RA on pain

8. Value of RA on pain
McCartney, Brull et al 2004

10. Value of RA on adverse events
McCartney, Brull et al 2004

12. What are other benefits of RA?
 Improved resp fnctn (Ballantyne et al)
 Faster return of GI function (Liu SS et al)
 Improved early ambulation (Ilfeld et al)
 Better sleep (Riazi S et al 2008)

13. Regional Anaesthesia
and Big Data
 Reduction in surgical site infection
 Reduced critical care utilization
 Faster discharge
 Reduced readmission
 Reduction in mortality

14. BMJ 2000

16.  400 hospitals between 2006-10
 Data from primary hip/knee arthroplasty
 Subgrouped by anesthetic technique
 30 day morbidity and mortality data
Anesthesiology 2013

17.  382,000 patients
 25% neuraxial
 Neuraxial associated with less mortality,
length of stay, in-patient morbidity
Anesthesiology 2013

21. Regional anesthesia Cancer outcomes

22. Chronic Pain

23.  23 RCTs in total
 Pooled 3 studies for epidural after
thoracotomy and 2 for PVB after breast
surgery
 Unable to pool data from other studies
due to marked heterogeneity

24. Andreae MH et al BJA 2013

25. RA and AVF patency

26. My own experience
 Edinburgh and Bruce Scott
 Dundee and Bill Macrae
 Aberdeen and Alistair Chambers
 Toronto and and Vincent Chan
 Multiple patients over 25 years

30. Regional Anaesthesia Risks

31. Look at the big picture
Guardian 11th September 2015

33. RAPM 2012

35. RA Risks: Central Techniques
 Neuropathy 2-3/10,000
 Haematoma 12.3/100,000
 Abscess 73/100,000
 Paraplegia or Death 0.7-1.8/100,000
Brull R et al 2005
Cook TM et al 2009
Cameron CM et al 2007

36. RA risks: PNB
 Seizures (5-20/10,000)
 Cardiac complications
 Pneumothorax (up to 6%)
 Respiratory failure
 Eye injuries
 Nerve injury (3-30/10,000)
 Death (1 case LPB)
Auroy Y 2002

37. Complications: Minor
 Pain during block performance
 Painful paresthesiae
 Post-block bruising/hematoma
 Intravascular injection
(tachycardia/hypertension)

41. Prevention and Management of
RA Risks
 Documented informed consent
 Balance of benefit vs risk
 Standardization of process and technique
 Just culture and learning from error
 Good training and use of effective
technique
 Doctor: Patient relationship

42. Informed Consent
 Discuss anaesthetic options and present
overview of risks
 In a timely fashion if possible
 Document the discussion clearly

43. Balance risk vs benefit

44. Balance risk vs benefit

45. Standardization

46. Standardization
 Preblock checklist
 Use standard technique (institution or
wider) or document why other technique
used
 Build a common approach across the
surgical team using agreed outcomes
 Follow up carefully

47. Preblock Checklist
www.edmariano.com

48. Just culture: learning from error

49. Just Culture and Medical Error
http://www.unmc.edu/patient-safety/_documents/patient-safety-and-the-just-culture.pdf

50. Training
Lenters et al 2007

51. Kathy Sierra: http://headrush.typepad.com/creating_passionate_users/2006/03/how_to_be_an_ex.html

52. Konrad et al Anesth Analg 1998

53. Existing Techniques to
Reduce Complications:
 Judicious sedation
 Nerve stimulation
 Epinephrine
 Negative aspiration
 Slow, incremental injection
 Safer local anesthetics
 Good training
Newer techniques
 Injection pressure
 Ultrasound
 Tissue impedance

54. “Our masters at NICE
have all spoken
This Scanner is not just a
token
To look with one eye
Is better then try
And end up with carotids
all broken”
Alastair Waite FRCA
Edinburgh 2004

55. Balancing Benefits and Risks
1. Get trained
2. Clear and documented informed consent
3. Team approach
4. Use your senses: Blood on aspiration, tissue
expansion (US), minimize pressure, nerve
expansion (US), slow, incremental injection
5. Beware low stimulation currents, pain on
injection, tachycardia
6. Follow up carefully

56. Summary
 Regional anaesthesia provides significant
benefits for our patients
 Risks are low but present
 A pragmatic approach that balances
benefit and risk is needed
 Clear explanation and documentation of
informed consent is important
 Regional anaesthesia is technically
demanding, beneficial and very satisfying

57. “Gentleness is the first requisite
of the anesthetist. He should
handle his patient and needle
with equal dexterity”
Gaston Labat 1922

58. cmccartney@toh.ca