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from http://www.rcseng.ac.uk/publications/docs/higher-risk-surgicalpatient (accessed 18 April 2012) 6 Centre for Workforce Intelligence. Shape of the medical workforce, 2012. Available from http://www.cfwi.org.uk/publications/leadersreport-shape-of-the-medical-workforce (accessed 18 April 2012)

4 BBC Health News article (9 March 2012). Available from http://www.bbc.co.uk/news/health-17305022 (accessed 18 April 2012) 5 The Royal College of Surgeons of England and the Department of Health. The Higher Risk General Surgical Patient, 2011. Available

British Journal of Anaesthesia 109 (1): 79 (2012) doi:10.1093/bja/aes169

EDITORIAL III

Regional anaesthesia for all?

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P. K. Gupta and P. M. Hopkins*

Section of Translational Anaesthetic and Surgical Sciences, Leeds Institute of Molecular Medicine, St Jamess University Hospital, Leeds LS9 7TF, UK * Corresponding author. E-mail: p.m.hopkins@leeds.ac.uk

In an issue focusing on quality and outcome, it is pertinent to consider whether regional anaesthetic techniques have such clear advantages that they should be offered to all patients, whether alone or in combination with general anaesthesia, when the surgical procedure is suitable. For some surgical procedures, it might even be relevant to debate if patients should be offered only a regional anaesthetic technique. Central neuraxial blocks have become an established and routine part of every anaesthetists technical armamentarium over the past 30 yr, and the increasing availability of ultrasound guidance over the past 15 yr1 2 has expanded the popularity among anaesthetists for use of an increasing range of regional anaesthetic techniques. It is timely, therefore, to consider the validity of frequently asserted clinical benets of regional anaesthesia made by its proponents. This will include impact on mortality in high-risk and low-risk procedures, benets in specic medical conditions, contrasting the severity and incidence of complications specic to regional anaesthesia and general anaesthesia, economic benets, and patient satisfaction. Finally, if all patients are to be offered the full range of anaesthetic techniques for their operation, we should consider the impact on training in regional anaesthesia. Kettner and colleagues3 recently grappled with some aspects of this debate but concluded that the absence of useful outcome data from meta-analyses and the minimal prospect of sufciently powered prospective randomized trials precluded any hope of establishing the primacy of regional or general anaesthesia. Our evidential outlook is broader and we recognize the value of epidemiological studies of rare events based on large data sets. For example, the national audit projects coordinated by the Royal College of Anaesthetists in the UK have led to estimates of mortality attributable to general anaesthesia of one in 180 000,4 and of paraplegia

or death resulting from central neuraxial block of one in 55 000.5 Similarly, Gottschalk and colleagues6 surmised that overall anaesthesia-related mortality was one in 145 000, but while overall mortality was directly correlated with increasing ASA status (one in 250 000, one in 20 000, one in 4000, and one in 200 for ASA status I, II, III, and IV, respectively), permanent complications of central neuraxial block are predicted rather by specic risk factors. Thus, Freise and colleagues7 concluded that adherence to guidelines leads to a high level of safety with thoracic epidural blocks and recommended their use in routine anaesthetic practice. Epidemiological studies have also provided clear evidence that central neuraxial anaesthesia carries a lower risk of mortality than general anaesthesia for obstetric patients.8 In ASA I patients having low-risk surgical procedures, the relatively higher risk of serious harm or death from central neuraxial anaesthesia, albeit based on rather crude data, perhaps favours general anaesthesia over central neuraxial block. The position is different, however, when a peripheral regional anaesthetic technique is a viable alternative to general anaesthesia. Closed-claim analyses from the USA indicate that permanent harm or death resulting from peripheral nerve block techniques are almost exclusively attributed to local anaesthetic toxicity.9 Ultrasound guidance has been shown to delineate anatomy,10 reduce block performance time,11 evaluate effective doses,12 improve success rate,13 and identify concomitant pathologies.14 It is likely that the incidence of local anaesthetic toxicity will be reduced by using ultrasound guidance,15 but evidence for the comparative safety of ultrasound guided nerve blocks is not yet available.16 Nerve injury is the other commonly asserted major problem with peripheral nerve blocks, and an experimental study in pigs17 has demonstrated the link between the magnitude of injury and the size of the needle perforating a

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nerve. Moore and colleagues18 looked at the spectrum of iatrogenic nerve injury in New Zealand by analysing treatment injury claims accepted by the national no-fault compensation scheme. They reviewed 313 iatrogenic nerve injuries for which they had sufcient information for analysis. The great majority resulted from direct surgical injury. The other leading causes of iatrogenic nerve injuries were malpositioning under general anaesthesia (12.9%) and venepuncture (8.3%). None of the injuries were specically attributed to peripheral nerve blocks, but one assumes any that did occur were included in the other injections category, which accounted for only 2.6% of the claims. In terms of safety, therefore, for operations amenable to anaesthesia using a peripheral nerve block technique, our advice to ASA I patients is that there is little to choose between regional and general anaesthesia. However with increasing ASA status, we believe the balance of risks favours regional anaesthesia. It may also be relevant that rare idiosyncratic (unpredictable) causes of major harm, in the form of malignant hyperthermia and drug allergy are, respectively, entirely19 or almost entirely20 avoided with regional anaesthesia compared with general. Aside from serious complications and death, evidence is emerging in support of better perioperative outcome with regional compared with general anaesthesia in terms of analgesia,21 22 deep vein thrombosis,23 myocardial events,24 pulmonary complications,25 and, more controversially, tumour recurrence rate.26 Richardson and colleagues27 in their review suggested that surgical ap survival may be better and chronic pain reduced in patients receiving bilateral paravertebral blocks. Regional anaesthesia avoids the risks of awareness under general anaesthesia, damage to teeth or eyes, and sore throat, although there is greater procedural discomfort. General anaesthesia is also associated with a greater incidence of nausea and vomiting. Many patients are concerned about the prospect of regional anaesthesia and some are unduly anxious, with perhaps the greatest concern being the possibility that they may be sensate of surgical pain.28 Provision of information before the procedure has been shown to considerably reduce anxiety in patients undergoing surgery under regional anaesthesia.29 Our experience is that patient satisfaction after the procedure is equally high for regional and general anaesthesia. If one accepts that regional anaesthesia using peripheral nerve blocks is at least not inferior to general anaesthesia for appropriate surgical procedures, a case might be made not to offer general anaesthesia if the costs of the regional anaesthetic technique were less. Health economic comparisons relevant to this scenario are few and they provide inconsistent results. Nordin and colleagues30 found regional anaesthesia and general anaesthesia to be equally expensive for inguinal hernia surgery. On the contrary, Gonano and colleagues31 demonstrated ultrasound-guided interscalene block to be signicantly more cost-effective than general anaesthesia for arthroscopic shoulder surgery. Perhaps the discrepancy can be partly explained by the fact that most surgical facilities have been designed for surgery conducted

Editorial III

under general anaesthesia. Efciency in provision of peripheral nerve block regional anaesthesia is improved if the surgical facility design and stafng is planned to accommodate the interval required for the block to develop and takes advantage of the need for a much shorter period of immediate postoperative monitored care. There is also the potential for one anaesthetist to be responsible for patients in more than one adjacent operating theatre if there are suitably trained staff to whom intraoperative monitoring can be delegated. Our experience of such a unit is that it does function well, but efciency is compromised when conversion to general anaesthesia is required. The major counterargument to such a regional anaesthesia only facility is the potential removal of patient autonomy in the decision about anaesthesia technique. The impact that this has depends on the values of the funder and provider of the service. In our opinion, the available evidence is insufcient for patient choice not to be an important determinant of anaesthetic technique and alternative arrangements should be made for patients electing for general anaesthesia. In summary, regional anaesthesia and general anaesthesia have contrasting inherent risks, which in healthy nonobstetric patients favour general anaesthesia over central neuraxial anaesthesia. When comparing the overall risk of general and peripheral nerve block regional anaesthesia, current evidence is too limited to make a distinction. For all types of regional anaesthesia, increasing ASA status shifts the balance in favour of avoiding general anaesthesia when possible. Where patient autonomy is valued, the implication is that anaesthetists should be able to offer an informed choice of a regional anaesthetic alternative to general anaesthesia for the relevant surgical procedure. Just as it is unthinkable that anaesthesia training programmes could produce specialists who are not competent to perform epidural or spinal anaesthesia, we consider competence in peripheral nerve block regional anaesthesia to be a prerequisite for anaesthesia specialist certication.

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Declaration of interest
P.M.H. has the use of ultrasound equipment loaned by SonoSite UK Ltd.

References
1 Marhofer P, Harrop-Grifths W, Kettner SC, Kirchmair L. Fifteen years of ultrasound guidance in regional anaesthesia: part 1. Br J Anaesth 2010; 104: 538 46 2 Marhofer P, Harrop-Grifths W, Willschke H, Kirchmair L. Fifteen years of ultrasound guidance in regional anaesthesia: part 2 recent developments in block techniques. Br J Anaesth 2010; 104: 673 83 3 Kettner SC, Willschke H, Marhofer P. Does regional anaesthesia really improve outcome? Br J Anaesth 2011; 107: i90 5 4 Cook TM, Woodall N, Frerk C. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difcult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011; 106: 617 31

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19 Hopkins PM. Malignant hyperthermiapharmacology of triggering. Br J Anaesth 2011; 107: 48 56 20 Harper NJ, Dixon T, Dugue P, et al. Suspected anaphylactic reactions associated with anaesthesia. Anaesthesia 2009; 64: 199211 21 Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anesthesia improve outcome after total knee arthroplasty? Clin Orthop Relat Res 2009; 467: 2379 402 22 Popping DM, Zahn PK, Van Aken HK, Dasch B, Boche R, Pogatzki-Zahn EM. Effectiveness and safety of postoperative pain management: a survey of 18 925 consecutive patients between 1998 and 2006 (2nd revision): a database analysis of prospectively raised data. Br J Anaesth 2008; 101: 832 40 23 Urwin SC, Parker MJ, Grifths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. Br J Anaesth 2000; 84: 450 5 24 Beattie WS, Badner NH, Choi P. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg 2001; 93: 853 8 25 Popping DM, Elia N, Marret E, Remy C, Tramer MR. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg 2008; 143: 9909 26 Snyder GL, Greenberg S. Effect of anaesthetic technique and other perioperative factors on cancer recurrence. Br J Anaesth 2010; 105: 106 15 27 Richardson J, Lonnqvist PA, Naja Z. Bilateral thoracic paravertebral block: potential and practice. Br J Anaesth 2011; 106: 164 71 28 Bridenbaugh LD. Regional anaesthesia for outpatient surgerya summary of 12 years experience. Can Anaesth Soc J 1983; 30: 54852 29 Jlala HA, French JL, Foxall GL, Hardman JG, Bedforth NM. Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. Br J Anaesth 2010; 104: 36974 30 Nordin P, Zetterstrom H, Carlsson P, Nilsson E. Cost-effectiveness analysis of local, regional and general anaesthesia for inguinal hernia repair using data from a randomized clinical trial. Br J Surg 2007; 94: 5005 31 Gonano C, Kettner SC, Ernstbrunner M, Schebesta K, Chiari A, Marhofer P. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. Br J Anaesth 2009; 103: 42833

5 Cook TM, Counsell D, Wildsmith JA. Major complications of central neuraxial block: report on the Third National Audit Project of the Royal College of Anaesthetists. Br J Anaesth 2009; 102: 179 90 6 Gottschalk A, Van Aken H, Zenz M, Standl T. Is anesthesia dangerous? Dtsch Arztebl Int 2011; 108: 469 74 7 Freise H, Van Aken HK. Risks and benets of thoracic epidural anaesthesia. Br J Anaesth 2011; 107: 85968 8 Cantwell R, Clutton-Brock T, Cooper G, et al. Saving Mothers Lives: reviewing maternal deaths to make motherhood safer: 2006 2008. The eighth report of the condential enquiries into maternal deaths in the United Kingdom. BJOG 2011; 118 (Suppl. 1): 1203 9 Lee LA, Posner KL, Cheney FW, Caplan RA, Domino KB. Complications associated with eye blocks and peripheral nerve blocks: an American Society of Anesthesiologists closed claims analysis. Reg Anesth Pain Med 2008; 33: 41622 10 Christophe JL, Berthier F, Boillot A, et al. Assessment of topographic brachial plexus nerves variations at the axilla using ultrasonography. Br J Anaesth 2009; 103: 60612 11 Brull R, Lupu M, Perlas A, Chan VW, McCartney CJ. Compared with dual nerve stimulation, ultrasound guidance shortens the time for infraclavicular block performance. Can J Anaesth 2009; 56: 8128 12 Gupta PK, Pace NL, Hopkins PM. Effect of body mass index on the ED50 volume of bupivacaine 0.5% for supraclavicular brachial plexus block. Br J Anaesth 2010; 104: 4905 13 Redborg KE, Antonakakis JG, Beach ML, Chinn CD, Sites BD. Ultrasound improves the success rate of a tibial nerve block at the ankle. Reg Anesth Pain Med 2009; 34: 25660 14 Sutin KM, Schneider C, Sandhu NS, Capan LM. Deep venous thrombosis revealed during ultrasound-guided femoral nerve block. Br J Anaesth 2005; 94: 247 8 15 Hopkins PM. Ultrasound guidance as a gold standard in regional anaesthesia. Br J Anaesth 2007; 98: 299 301 16 Neal JM. Ultrasound-guided regional anesthesia and patient safety: an evidence-based analysis. Reg Anesth Pain Med 2010; 35: S5967 17 Steinfeldt T, Nimphius W, Werner T, et al. Nerve injury by needle nerve perforation in regional anaesthesia: does size matter? Br J Anaesth 2010; 104: 245 53 18 Moore AE, Zhang J, Stringer MD. Iatrogenic nerve injury in a national no-fault compensation scheme: an observational cohort study. Int J Clin Pract 2012; 66: 409 16

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British Journal of Anaesthesia 109 (1): 912 (2012) doi:10.1093/bja/aes177

EDITORIAL IV

Continuous thoracic epidural block for surgery: gold standard or debased currency?
J. A. W. Wildsmith*
Department of Anaesthesia, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK * E-mail: jaww@doctors.org.uk

Thirty years ago, continuous epidural block was used during and after surgery of the trunk by only a few dedicated

enthusiasts following the example set by pioneers such as Dawkins.1 The method was usually reserved for very major