Transcript GALA Review of LA vs GA

GA versus LA
The Story So Far
Dr Andrew R Bodenham
The General Infirmary at Leeds
Funding: Health Foundation, ESVS
“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.”
Funding: Health Foundation, ESVS
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
Funding: Health Foundation, ESVS
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)
Funding: Health Foundation, ESVS
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
Funding: Health Foundation, ESVS
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
Funding: Health Foundation, ESVS
Why might LA be safer ?
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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
Funding: Health Foundation, ESVS
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 ?
Funding: Health Foundation, ESVS
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
Funding: Health Foundation, ESVS
Putative Cost Benefits of LA
• Less workup
• Less monitoring
• £££; drugs, shunt, other consumables
• Avoid HDU/ITU
• Quicker mobilisation
• Shorter Hospital stay
• Avoid expensive complications
Funding: Health Foundation, ESVS