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GA versus LA The Story So Far

GA versus LA The Story So Far. Dr Andrew R Bodenham The General Infirmary at Leeds. “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.”. Why the Debate: LA versus GA.

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GA versus LA The Story So Far

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  1. GA versus LA The Story So Far Dr Andrew R Bodenham The General Infirmary at Leeds

  2. “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.”

  3. 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

  4. 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)

  5. 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

  6. 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

  7. 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

  8. 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 ?

  9. 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

  10. Putative Cost Benefits of LA • Less workup • Less monitoring • £££; drugs, shunt, other consumables • Avoid HDU/ITU • Quicker mobilisation • Shorter Hospital stay • Avoid expensive complications

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