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R.A. for high-risk patients

R.A. for high-risk patients. Olivier Choquet Department of Anesthesiology and Critical Care Medicine Lapeyronie University Hospital Montpellier, France. DISCLOSURE. The high risk patient Menu. The risk of complication Surgery - Anesthesia - Pulmonary - Cardiac

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R.A. for high-risk patients

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

  2. DISCLOSURE

  3. The high risk patientMenu • The riskof complication • Surgery - Anesthesia - Pulmonary - Cardiac • The Risk of Medical liability • Anesthesist - GA - RA • The stratagem • Think different ! • Conclusion

  4. High risk patient for surgeryIntraoperative 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.difficultairway – full stomach… • Obese – pediatriclymphoma – 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 A 5:10.000 • Systemic toxicity 5:10.000 Transient neuropathy after spinal / epidural anesthesia 2-4:10.000 PNB 100:10.000 Permanent neurological injury after spinal / epidural anesthesia 0-4:10.000 PNB0-1:10.000 • Death – brain damage 0-1:100.000 • AuroyAnesthesiology 2002 Severe complications are uncommon

  9. Pulmonary risk: easy ! • If possible, • prefera regional

  10. Cardiac riskGeneral vs. Regional • ADVANTAGESof regional in the cardiac pt. • Less myocardial, respiratory depression • Avoid endotracheal intubation (autonomic stimulation) • DISADVANTAGESof 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 riskGeneral 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. AnesthAnalg 2003; 96: 548. Rigg JRA et al. Lancet 2002; 359: 1276. Ballantyne J clinanesth 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 valvulardisease • Diabetes - Renal insufficiency • Type of surgery • Gupka circulation 2011 – Lidenauer NEJM 2005

  13. Cardiac riskstratification: 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 patientMenu • The riskof complication • Surgery - Anesthesia - Pulmonary - Cardiac • The Risk of Medical liability • Anesthesist - GA - RA • The stratagem • Think different ! • Conclusion

  16. Complications are rare but highlightedwhat 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 claims 80 % 1000 regional anesthesia claims 20 % 800 neuraxialblockade 16% 200 PNB (& eye blocks) 4% 20 years - USA

  20. Trends in Damaging Events: RA • 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 anesthetictoxicity • Most PNB claims associated with temporary injuries

  21. Cost of litigation: RA < GA

  22. According to the ASA Closed Claims Reviews, airway adverse events still represent the greatest cause of liability and the largest awards owing to malpractice. The classical alternative: spinal vs general If possible, don’t manipulate the airway DH. Lambert, PhD, MD Boston University School of Medicine 2006

  23. Number of claims (1999-2009) GAMM insurancecompagnyIn France 10 years - 2500 claims - 1500 Anesthetists 1500 GA 75% 400 Post op 15% 50Position 5% 300RA 11% 100spinal 3 % • 100epidural 3 % • 100PNB 3 %

  24. 419 No deathrelated to PNB

  25. Root causes specific to general anesthesia complications

  26. The high risk patientMenu • The riskof complication • Surgery - Anesthesia - Pulmonary - Cardiac • The Risk of Medical liability • Anesthesist - GA - RA • The stratagem • Think different ! • Conclusion

  27. Riskbased on the activity Amateur system artistic Hihtsafe system Bank controlled Safe system controlled… No infaillible system known to dateist… Medicine Hymalaya climber nuclear car railway airplane One disasterout of 1 000 000 One disasterout of 100 One disasterout of 1 000 One disasterout of 10 000 One disasterout of 100 000

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

  29. Risk: RegionalAnesthetia Amateur system artistic Hihtsafe system Bank controlled Safe system controlled… Transientneuropathy ISB axBFB Permanent neuropathy PNB Seizure Toxsyst Braindamage SystTox No infaillible system known to dateist… epidural obstetrics spinal orthopedics Cardiacarrest / spinal Paraplegia / epidural Cardiacsurgery patient ASA 3-4 General surgery patient ASA 1 2 Medicine Hymalaya climber nuclear car railway airplane One disasterout of 1 000 000 One disasterout of 100 One disasterout of 1 000 One disasterout of 10 000 One disasterout of 100 000

  30. High risk patient: general Amateur system artistic Hihtsafe system Bank controlled Safe system controlled… >80ans ASA 3 Heartfailure Coronaropathy Emergency SAOS …. AG No infaillible system known to dateist… Medicine Hymalaya climber nuclear car railway airplane One disasterout of 1 000 000 One disasterout of 100 One disasterout of 1 000 One disasterout of 10 000 One disasterout of 100 000

  31. High risk patient: spinal Amateur system artistic Hihtsafe system Bank controlled Safe system controlled… >80ans ASA 3 Heartfailure Coronaropathy Emergency SAOS …. AG No infaillible system known to dateist… Medicine Hymalaya climber nuclear car railway airplane One disasterout of 1 000 000 One disasterout of 100 One disasterout of 1 000 One disasterout of 10 000 One disasterout of 100 000

  32. High risk patient: PNB Amateur system artistic Hihtsafe system Bank controlled Safe system controlled… >80ans ASA 3 Heartfailure Coronaropathy Emergency SAOS …. AG No infaillible system known to dateist… Medicine Hymalaya climber nuclear car railway airplane One disasterout of 1 000 000 One disasterout of 100 One disasterout of 1 000 One disasterout of 10 000 One disasterout of 100 000

  33. The high risk patient • Plan A plan B Plan C Benefit/ risks / stratification The choice

  34. The high risk patientMenu • The riskof complication • Surgery - Anesthesia - Pulmonary - Cardiac • The Risk of Medical liability • Anesthesist - GA - RA • The stratagem • Think different ! • Conclusion

  35. 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

  36. 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 therapyinstituted • Infection at the injection site • RA Performed in healthy area (supraclavicular…) ! • True Allergy to L.A. • Ensure that it is a “true” allergy

  37. 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. No; if i don'tperform a GA May I die, doctor

  38. Be persuasive ! • Because safety >>> comfort • Riskbenefit ratio : Explain – Refute!!

  39. 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

  40. Absolute Contraindicationsto 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

  41. PNB in high risk patients

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

  43. Root causes specific to regional anaesthesia complications • High doses of L.A. • Insufficientphysicianexperience • Excessive (uncontrolled) sedation • “less than gentle” RA technique • Inadequate or perilousprocedures • No “back up” plan been made in the event of a failure of the RA technique

  44. 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 !

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