Funding: Health Foundation, ESVS 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; BMJ Rodgers 2000; 321: 1493 (also in bandolier) Lancet 2008; 372: Best practice and research anaesthesia 2006;20:

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