Chapter

Outcome issues

Susan Nimmo and Graeme McLeod

in Principles and Practice of Regional Anaesthesia

Fourth edition

Published on behalf of Oxford University Press

Published in print November 2012 | ISBN: 9780199586691
Published online November 2012 | e-ISBN: 9780191755507 | DOI: http://dx.doi.org/10.1093/med/9780199586691.003.0005

Series: Oxford Textbooks in Anaesthesia

Outcome issues

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The debate on the benefit (or not) of using ‘local’ techniques for surgical anaesthesia is one which dates back to the middle of the 19th century, ‘cold’ having been proposed as ‘safer’ than ether or chloroform long before cocaine came into use (Arnott 1847). Refrigeration had limited application, as did cocaine, but improvements in drugs and their application made for better effectiveness and wider applicability so that topical, infiltration, and minor nerve block techniques are used widely today. General anaesthesia is not only unnecessary, but inappropriate for many minor dental and surgical procedures, local methods preserving both consciousness and the patient’s protective reflexes to allow a single-handed practitioner to operate in safety. This approach also contributes to that most modern of healthcare outcomes, reduced expenditure, because drug and equipment costs are significantly less. That was always an issue in developing countries, but has become important everywhere. However, once surgery requires an anaesthetic team, the staff costs far outweigh all others and the economic difference between regional and general techniques is minimal (Kendell et al. 2000). Refrigeration anaesthesia was advocated as a means of avoiding the major morbidity, and mortality, associated with early general anaesthesia, but regional techniques have their own risks. When central neuraxial block began to displace general anaesthesia in obstetrics 30–40 years ago, it was argued that unskilled use would be at least as dangerous, and not necessarily reduce the overall incidence of anaesthesia-related death. Obviously clinicians must be trained in all aspects of the methods which they are using, not forgetting the treatment of complications, but their ease of management is an issue also. Failure to intubate the trachea and aspiration of gastric content are, intuitively, much more difficult to manage than hypotension of sympathetic origin, no matter how skilled the anaesthetist (Rosen 1981). The reduction in the number of maternal deaths due to ‘anaesthetic’ factors recorded in both the UK and the USA with the progressive change to central nerve block for Caesarean section has proved this to be so (Hawkins et al. 1997, Reports 1952 to 2011). Chapter 3 describes how regional methods offer other features (ablation of the surgical stress response, and a reduction in the incidence and severity of side effects) which may lead to patient benefit. However, when and where modern standards of care are available, any overall advantage in favour of regional techniques is not as obvious as in the two very different situations described previously. As a result many comparative studies, and subsequent meta-analyses, have been performed over the last 40 years to try and identify the ‘best’ approach. That the debate still continues is a clear indication that no definitive evidence has appeared, and the rest of this chapter aims to consider a range of ‘outcomes’ to provide a guide to clinical decision-making. First, three key points should be made, albeit with some qualification: 1. Not one study, whether of minor or major sequelae of anaesthesia and surgery, has even hinted that regional techniques are associated with more negative outcomes than general anaesthesia. The ‘worst’ that can be said is that there is no overall difference between them, although the pattern of sequelae may be different. 2. Conversely, every comparison has shown that regional methods are associated with a very obvious decrease in pain, certainly in the early postoperative period. Of course, the effect will regress and pain will develop eventually, but it is much less severe and more readily controlled than if a block is not used. 3. There is concern that this improved postoperative analgesia is offset by the risk of neurological complications of the block technique. These are considered in detail in Chapter 4 and, while they can be catastrophic for the individual patient, they are extremely rare.

Chapter.  6611 words. 

Subjects: Anaesthetics ; Medical Statistics and Methodology

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