Expanding Role of Regional Anesthesia

Ottawa - Regional anesthesia is an effective, cost-efficient technique with largely untapped potential, those attending the 52nd annual meeting of the Canadian Anesthetists' Society learned recently. Participants at the symposium "Expanding the Role of Regional Anesthesia" heard from three experts in the field - Drs. David Brown, Himat Vaghadia, and Brendan Finucane. The symposium was approved by the RCPSC for MOCOMP credits and was made possible through an education grant from Astra Pharma Inc.
The presenters' overall message was that regional anesthesia is highly effective for many surgical procedures and post-operative pain management, has fewer adverse effects and sequelae than general anesthetic, promotes economy of time and money, and improves patients' quality of life - but patients and practitioners alike are not aware of this.
Dr. Brown, who is a consultant anesthesiologist at the Mayo Clinic, noted that regional anesthesia is superior to general anesthesia with regards to several criteria: stress response, coagulation function, severity of acute pain, plasticity of nervous system, blood loss, nausea and vomiting, and sequelae. "Pre-emptive" anesthesia before incision speeds recovery of function, he said. Although preparation time might be slightly longer with regional anesthesia, patient positioning and incision times are shorter. Recovery is faster, and patients experience fewer side effects and sequelae, especially after major surgery. In short, Dr. Brown said, regional anesthesia should be promoted "whenever the surgical procedure can be accomplished without significant adverse patient outcome."
He also noted that regional anesthesia is highly effective in post-operative and labor pain management. A study of terminally ill patients with significant pre-operative pain showed that a regional block for post-operative pain management could extend life without diminishing its quality. Despite all these advantages, use of regional anesthesia did not increase significantly over the decade 1980 - 1990 except for post-operative epidural anesthesia. Dr. Brown suggested that anesthetists counter this lack of use by concentrating on several areas: developing better catheters; refining block imaging techniques; increasing efficiency; accurately estimating risks; improving skills, and understanding how to use mixed regional and general anesthesia.
Dr. Vaghadia's topic - pharmacoeconomic considerations - was especially timely in this era of budget restrictions. The director of ambulatory anesthesia at the Vancouver Hospital and Health Sciences Centre noted that all the medical advantages of regional anesthesia are also economic advantages, because patients need less attention, require fewer medications, leave hospital more quickly, and are readmitted less often. This translates into savings - as much as $3,000 in the case of knee surgery.
Given this, it is unfortunate that outpatient surgery in North America involves regional anesthesia only 2% - 5% of the time as compared with Europe's average of 36%. "The practice of regional anesthesia in North America has a potential to grow in excess of 700%; however . . . we, the surgeons, and the patients must first be convinced that such a change in practice is cost effective," Dr. Vaghadia said.
Dr. Vaghadia noted that 95% of anesthetists and patients with previous surgical experience choose regional anesthesia. He also mentioned that this approach addresses the blood-supply problem: regional anesthesia benefits patients by reducing blood loss, and patients' fears of receiving tainted transfusions are allayed.
Dr. Finucane is chairman of the department of anesthesia at the University of Alberta Hospitals in Edmonton. He reported that a mail survey of surgeons across Canada (37% responded) showed that they were predominantly positive about regional anesthesia, but 30% admitted to having discouraged patients from choosing it. He also reported that 68% of anesthetists would choose regional anesthesia for themselves but, as he put it, "it is not a popular choice" for their patients.
Dr. Finucane said that there are many reasons for this situation: patients fear pain and awareness of what is happening; surgeons believe that it slows the process; anesthetists find general anesthesia easier; medications and techniques are not properly understood; facilities are often inadequate.
Like his colleagues, Dr. Finucane emphasized that there was a great need for education. Anesthetists must enhance their own understanding about regional anesthesia and then educate patients, referring physicians, and surgeons. Dr. Finucane also recommended conducting more studies and workshops, and he ended the presentations with a thought-provoking question: Is there a need for a Canadian anesthetists' society of regional anesthesia?

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