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
The Risk of Medical liability
Anesthesist - GA - RA
The stratagem
Think different !
Conclusion
High risk patient for surgery
Intraoperative 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 Risk patient for G.A.
difficult airway – full stomach…
Obese – pediatric lymphoma – obstetrics…
:
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
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
Cardiac arrest after spinal A
5:10.000
Systemic toxicity
5:10.000
Transient neuropathy after
spinal / epidural anesthesia
PNB
2-4:10.000
100:10.000
Permanent neurological injury after
spinal / epidural anesthesia
PNB
0-4:10.000
0-1:10.000
Death – brain damage
0-1:100.000
Auroy Anesthesiology 2002
Severe complications are uncommon
Pulmonary risk: easy !
If possible,
prefer a regional
Cardiac risk
General vs. Regional
ADVANTAGES of regional in the cardiac pt.
Less myocardial, respiratory depression
Avoid endotracheal intubation (autonomic stimulation)
DISADVANTAGES of 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. 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. Anesth Analg 2003; 96: 548.
Rigg JRA et al. Lancet 2002; 359: 1276.
Ballantyne J clin anesth 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
ASA Class - Functional status – Age
Ischemic heart disease - heart Failure
Cerebrovascular disease
Significant arrhythmias
Severe valvular disease
Diabetes - Renal insufficiency
Type of surgery
Gupka circulation 2011 – Lidenauer NEJM 2005
Cardiac risk
stratification: 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
No data concerning PNB …
The high risk patient
Menu
The risk of 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?
G.A versus Neuraxial A. versus PNB ?
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
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.
20 years - USA
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 neuraxial blockade
16%
200 PNB (& eye blocks)
4%
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 anesthetic
toxicity
Most PNB claims associated with temporary injuries
Cost of litigation: RA < GA
According to the ASA Closed Claims Reviews, airway
adverse events still represent the greatest cause of
liability and the largest awards owing to malpractice.
If possible, don’t manipulate the airway
The classical alternative: spinal vs general
DH. Lambert, PhD, MD
Boston University School of Medicine 2006
Number of claims (1999-2009)
GAMM insurance compagny In France
10 years - 2500 claims - 1500 Anesthetists
1500
GA
75%
400
Post op
15%
50
Position
300
RA
100
100
100
5%
11%
spinal
epidural
PNB
3%
3%
3%
419
No death related to PNB
Root causes specific to
general anesthesia complications
The high risk patient
Menu
The risk of complication
Surgery - Anesthesia - Pulmonary - Cardiac
The Risk of Medical liability
Anesthesist - GA - RA
The stratagem
Think different !
Conclusion
Risk based on the activity
Amateur system
artistic
One disaster
out of 100
No infaillible system
known to dateist…
Hymalaya
climber
Hiht safe system
Bank controlled
Safe system
controlled…
Medicine
car
One disaster
out of 1 000
airplane
One disaster
out of 10 000
railway
One disaster
out of 100 000
nuclear
One disaster out
of 1 000 000
Risk: General Anesthetia
Amateur system
artistic
Hiht safe system
Bank controlled
Safe system
controlled…
Risque anesthésique
Hymalaya
climber
One disaster
out of 100
Cardiac surgery
patient ASA 3-4
Medicine
car
One disaster
out of 1 000
General surgery
patient ASA 1 2
airplane
One disaster
out of 10 000
railway
One disaster
out of 100 000
No infaillible system
known to dateist…
Blood
transfusion
nuclear
One disaster out
of 1 000 000
Risk: Regional Anesthetia
Amateur system
artistic
Hiht safe system
Bank controlled
Safe system
controlled…
Seizure
Tox syst
Brain damage Syst Tox
spinal
orthopedics
Hymalaya
climber
One disaster
out of 100
Cardiac surgery
patient ASA 3-4
General surgery
patient ASA 1 2
Medicine
car
One disaster
out of 1 000
epidural
obstetrics
Cardiac arrest / spinal
Paraplegia / epidural
airplane
One disaster
out of 10 000
railway
One disaster
out of 100 000
No infaillible system
known to dateist…
Permanent
neuropathy
PNB
Transient neuropathy
ISB
axB
FB
nuclear
One disaster out
of 1 000 000
High risk patient: general
Amateur system
artistic
Hiht safe system
Bank controlled
Safe system
controlled…
Hymalaya
climber
One disaster
out of 100
No infaillible system
known to dateist…
>80ans
ASA 3
Heart failure
Coronaropathy
Emergency
SAOS
….
AG
Medicine
car
One disaster
out of 1 000
airplane
One disaster
out of 10 000
railway
One disaster
out of 100 000
nuclear
One disaster out
of 1 000 000
High risk patient: spinal
Amateur system
artistic
Hiht safe system
Bank controlled
Safe system
controlled…
Hymalaya
climber
One disaster
out of 100
No infaillible system
known to dateist…
>80ans
ASA 3
Heart failure
Coronaropathy
Emergency
SAOS
….
AG
Medicine
car
One disaster
out of 1 000
airplane
One disaster
out of 10 000
railway
One disaster
out of 100 000
nuclear
One disaster out
of 1 000 000
High risk patient: PNB
Amateur system
artistic
Hiht safe system
Bank controlled
Safe system
controlled…
Hymalaya
climber
One disaster
out of 100
No infaillible system
known to dateist…
>80ans
ASA 3
Heart failure
Coronaropathy
Emergency
SAOS
….
AG
Medicine
car
One disaster
out of 1 000
airplane
One disaster
out of 10 000
railway
One disaster
out of 100 000
nuclear
One disaster out
of 1 000 000
The high risk patient
Plan A
plan B
Plan C
Benefit / risks / stratification
The choice
The high risk patient
Menu
The risk of complication
Surgery - Anesthesia - Pulmonary - Cardiac
The Risk of Medical liability
Anesthesist - GA - RA
The stratagem
Think different !
Conclusion
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
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 therapy instituted
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 ?
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
No; if i
should be considered.
May I
die,
doctor
don't
perform
a GA
Be persuasive !
Because safety >>> comfort
Risk benefit ratio : Explain – Refute !!
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 Contraindications to 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
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
High doses of L.A.
Insufficient physician experience
Excessive (uncontrolled) sedation
“less than gentle” RA technique
Inadequate or perilous procedures
No “back up” plan been made in the event of a
failure of the RA technique
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 !