1. R.A. for high-risk patients Olivier Choquet Department of Anesthesiology and Critical Care Medicine Lapeyronie University Hospital Montpellier, France

2. DISCLOSURE

3. 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

4. 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

5. High Risk patient for G.A. difficult airway – full stomach… Obese – pediatric lymphoma – obstetrics… :

6. 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 ?

7. 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

8. Risk of severe complications after RA Cardiac arrest after spinal A5:10.000 Systemic toxicity5:10.000 Transient neuropathy after spinal / epidural anesthesia 2-4:10.000 PNB100:10.000 Permanent neurological injury after spinal / epidural anesthesia 0-4:10.000 PNB0-1:10.000 Death – brain damage0-1:100.000 Auroy Anesthesiology 2002 Severe complications are uncommon

9. Pulmonary risk: easy ! If possible, prefer a regional

10. 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

11. 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

12. 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

13. 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

14. No data concerning PNB …

15. 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

16. Complications are rare but highlighted what is the risk of claim? G.A versus Neuraxial A. versus PNB ?

17. 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

18. 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.

19. adverse anesthetic outcomes collected from closed anesthesia malpractice insurance claims 35 professional liability companies About 5000 claims 3000 other claims80 % 1000 regional anesthesia claims 20 % 800 neuraxial blockade 16% 200 PNB (& eye blocks)4% 20 years - USA

20. 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 Trends in Damaging Events: RA

21. Cost of litigation: RA < GA

23. The classical alternative: spinal vs general DH. Lambert, PhD, MD Boston University School of Medicine 2006 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

24. 10 years - 2500 claims - 1500 Anesthetists 1500GA 75% 400Post op15% 50Position 5% 300RA11% 100spinal 3 % 100epidural 3 % 100PNB 3 % Number of claims (1999-2009) GAMM insurance compagny In France

25. 419 No death related to PNB

27. Root causes specific to general anesthesia complications

28. 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

29. One disaster out of 100 One disaster out of 1 000 One disaster out of 10 000 One disaster out of 100 000 One disaster out of 1 000 000 Hymalaya climber Medicine railway airplane nuclear car Amateur system artistic Safe system controlled… Hiht safe system Bank controlled No infaillible system known to dateist… Risk based on the activity

30. One disaster out of 100 One disaster out of 1 000 One disaster out of 10 000 One disaster out of 100 000 One disaster out of 1 000 000 Hymalaya climber Medicine railway airplane nuclear car Amateur system artistic Safe system controlled… Hiht safe system Bank controlled No infaillible system known to dateist… Risk: General Anesthetia Risque anesthésique Blood transfusion Cardiac surgery patient ASA 3-4 General surgery patient ASA 1 2

31. One disaster out of 100 One disaster out of 1 000 One disaster out of 10 000 One disaster out of 100 000 One disaster out of 1 000 000 Hymalaya climber Medicine railway airplane nuclear car Amateur system artistic Safe system controlled… Hiht safe system Bank controlled No infaillible system known to dateist… Risk: Regional Anesthetia Cardiac surgery patient ASA 3-4 General surgery patient ASA 1 2 Cardiac arrest / spinal Paraplegia / epidural epidural obstetrics spinal orthopedics Transient neuropathy ISB axBFB Permanent neuropathy PNB Seizure Tox syst Brain damage Syst Tox

32. One disaster out of 100 One disaster out of 1 000 One disaster out of 10 000 One disaster out of 100 000 One disaster out of 1 000 000 Hymalaya climber Medicine railway airplane nuclear car Amateur system artistic Safe system controlled… Hiht safe system Bank controlled No infaillible system known to dateist… High risk patient: general >80ans ASA 3 Heart failure Coronaropathy Emergency SAOS …. AG

33. One disaster out of 100 One disaster out of 1 000 One disaster out of 10 000 One disaster out of 100 000 One disaster out of 1 000 000 Hymalaya climber Medicine railway airplane nuclear car Amateur system artistic Safe system controlled… Hiht safe system Bank controlled No infaillible system known to dateist… High risk patient: spinal >80ans ASA 3 Heart failure Coronaropathy Emergency SAOS …. AG

34. One disaster out of 100 One disaster out of 1 000 One disaster out of 10 000 One disaster out of 100 000 One disaster out of 1 000 000 Hymalaya climber Medicine railway airplane nuclear car Amateur system artistic Safe system controlled… Hiht safe system Bank controlled No infaillible system known to dateist… High risk patient: PNB >80ans ASA 3 Heart failure Coronaropathy Emergency SAOS …. AG

35. The high risk patient Plan Aplan BPlan C Benefit / risks / stratification The choice

36. 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

37. 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

38. 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

39. 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 should be considered. May I die, doctor No; if i don't perform a GA

40. Be persuasive ! Because safety >>> comfort Risk benefit ratio : Explain – Refute !!

41. 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

42. 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

43. PNB in high risk patients

44. Combined lumbar and sacral plexus Block Secured under ultrasound guidance Appropriate conditions for surgery, hemodynamic stability, and postoperative analgesia

45. 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

46. 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 !