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October 2002
Volume 66 |
Number 10
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SUBSPECIALTY NEWS
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Has General Anesthesia Become
Obsolete in the United States?
James C. Eisenach,
M.D., President
American Society of Regional Anesthesia and Pain Medicine
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Imagine yourself or your spouse having extensive arthroscopic
shoulder surgery as an outpatient. What kind of anesthesia
would you chose? Most likely it would be general anesthesia.
Knowing that pain is often severe for at least 12 hours
after this surgery, what kind of analgesia would you chose?
Many would prefer an interscalene block. Time and time again
when anesthesiologists are surveyed regarding their preference
for anesthesia for themselves, they choose regional anesthesia
at a much higher percentage for themselves than they administer
for their patients. Why might this be?
As NEWSLETTER Editor Mark J. Lema, M.D., Ph.D.,
noted (somewhat tongue-in-cheek) in his article, "Has
Regional Anesthesia Become Obsolete in the United States?"
in the August issue of the ASA NEWSLETTER, there
is a perception that regional anesthesia is dying in the
United States. The reasons for this perception are clearly
indicated in his article: extra time needed for regional
anesthesia, no clear safety benefit compared to newer, safer
general anesthetic drugs and techniques, and lack of personnel
in training centers interested in teaching regional anesthesia.
Although these perceptions exist in many centers, there
has been a dramatic overall shift in interest in regional
anesthesia with research indicating significant benefits
of regional anesthesia and with the development of better
methods to teach regional anesthesia in the United States
over the last decade.
Then…
Twenty-five years ago, it was understood that all U.S. residents
were to master the knowledge and techniques necessary for
general anesthesia. Yet there was a pervasive attitude that
regional anesthesia was more of an art than general anesthesia,
required very different skills and was attainable only by
the gifted few. This attitude can be attributed to the use
of "blind" techniques, relying on the poorly described
tactile sense of needle advancement and practitioner experience.
Prominent teachers of regional anesthesia disagreed strongly
with each other on even the basic anatomy of the peripheral
nerves, how blocks should be performed and how much local
anesthetic should be administered. In many institutions,
intravenous sedation was routinely administered during and
after the placement of peripheral nerve blocks to the extent
that it was difficult to determine the efficacy of the block.
Fellowships in regional anesthesia presupposed that only
a few could master these complex, mysterious and tricky
techniques. It is not surprising that anesthesiology residents
at the end of their training 25 years ago rarely ventured
beyond the occasional spinal or axillary block. Even those
trained in the art of regional anesthesia did not use these
techniques if they entered a practice where regional anesthesia
was not already established. In many ways, one could say
that regional anesthesia at this time was an intellectual
curiosity, of minimal practical consequence, and was essentially
dead as a viable technique for routine use in the United
States.
…and Now
Regional anesthesia in 2002, in contrast, is alive
and well. In my opinion, the increased interest and practice
of regional anesthesia reflects two important changes in
education of these techniques. The first is the now routine
use of nerve stimulators, allowing one to demonstrate the
functional anatomy of peripheral nerves and their divisions
with clear endpoints and more certain knowledge of where
the needle tip lies in relation to the nerve. Comparing
this to the older description of the feel of "pops"
by the teacher holding the needle him/herself is akin to
comparing the current teaching of laparoscopic surgery when
all can see the procedure on the video screen, to previously
when the chief surgeon, peering through the objective of
the laparoscope, described the surgery to the resident.
Education of regional anesthesia also is improved by the
now routine use of cadaveric anatomic specimens to demonstrate
peripheral neural anatomy. Many programs now incorporate
teaching sessions in the gross anatomy lab for their residents,
and intensive workshops at the Annual Meeting of the American
Society of Regional Anesthesia and Pain Medicine (ASRA)
as well as other self-standing workshops rely heavily on
hands-on experience for the practitioner wishing to review
regional anesthesia and renew or learn skills.
Finally, we are becoming increasingly aware of the benefits
of regional anesthesia and applying it to a wider set of
patients and circumstances. Few argue that regional anesthesia
reduces mortality compared to general anesthesia, although
there are some indications that this may be so in special
populations. However, analgesia following surgery from appropriate
central or peripheral nerve block is unrivaled. Often opioids
can be removed totally from the postoperative pain regimen,
avoiding their numerous bothersome and occasionally dangerous
side effects. Recent work from our research laboratory and
others suggests that regional anesthesia may reduce the
incidence of chronic pain following surgery, which, as indicated
in Dr. Lema's article, is particularly high after amputation
and thoracic surgery. Thus, just as acute beta-adrenergic
blockade at the time of surgery may have prolonged benefits
for months to reduce patient mortality in high-risk populations,
so may regional anesthesia at the time of surgery prevent
the devastating consequences of chronic pain.
This article was not meant to be a debate with Dr. Lema,
my colleague on the ASRA Board of Directors. He did, however,
provide an easy straw man to knock down. Indeed, regional
anesthesia is far from becoming obsolete in the United States,
thanks in large part to new methods to teach and perform
these techniques easily.
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James
C. Eisenach, M.D., is the Francis M. James III Professor
of Anesthesiology and Vice-Chair for Research at Wake
Forest Medical Center, Winston-Salem, North Carolina. |
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