Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
GA versus LA The Story So Far Dr Andrew R Bodenham The General Infirmary at Leeds Funding: Health Foundation, ESVS “This patient is rather frail with multiple co-morbidities so I have told her it is safer to perform her carotid surgery under local anaesthetic.” Funding: Health Foundation, ESVS Why the Debate: LA versus GA • Increasing demand for surgical procedures • High risk patients (IHD, DM, COPD, elderly) • Elective surgery: A numbers game: Risk of procedure versus long term benefit • Safer procedures might allow more patients to benefit from intervention Funding: Health Foundation, ESVS What is a GA ? • Unconscious patient throughout • Artificial airway, paralysis, ventilation • Volatile or intravenous anaesthesia • Loss of systemic/cerebral autoregulation • Indirect physiological monitoring • Possible Cerebral protection • Occasional anaesthetic catastrophes (1:250000) Funding: Health Foundation, ESVS What is a LA technique ? In ascending complexity • Topical LA (e.g. eye) • Local infiltration surgical wound • Superficial nerve block • Deep nerve plexus block • Spinal/epidural Sedation or GA can be added to any of the above LA provides intra op and post op anaesthesia/analgesia Funding: Health Foundation, ESVS LA vs GA • Intuitive that a minor procedure on skin surface under topical or infiltration anaesthesia should be safer without a GA: e.g. cataract under topical LA • But as surgery gets more invasive with greater tissue injury & stress response, and local anaesthetic techniques become more invasive, the benefit of LA over GA becomes blurred Funding: Health Foundation, ESVS Why might LA be safer ? • • • • • • Definitive CNS monitoring Maintenance cerebral/coronary autoregulation Better post op pain relief Early mobilisation Lower risk of respiratory problems and DVT Reduced stress response to surgery • Avoid the other complications specific to GA Funding: Health Foundation, ESVS Rarer Anaesthetic Complications • Approx 1% risks not discussed with patients Airway events, hypoxia Adverse drug reactions Complications of central venous access MI, stroke, DVT, chest infection • Are these reduced by Local Anaesthesia ? Funding: Health Foundation, ESVS Evidence for GA vs LA in Other Surgical Procedures • Cataracts, hip fracture, other major surgery Some large controlled studies • Studies have compared GA v Local infiltration GA v regional nerve block GA with and without regional nerve block • No clear benefit established ! MASTER study Lancet 2002; 359; 1276-82 BMJ Rodgers 2000; 321: 1493 (also in bandolier) Lancet 2008; 372:562-569 Best practice and research anaesthesia 2006;20: 249-63 Funding: Health Foundation, ESVS Putative Cost Benefits of LA • Less workup • Less monitoring • £££; drugs, shunt, other consumables • Avoid HDU/ITU • Quicker mobilisation • Shorter Hospital stay • Avoid expensive complications Funding: Health Foundation, ESVS