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August 2002
Volume 66 |
Number 8
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VENTILATIONS
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| Has Regional
Anesthesia Become Obsolete in the United States? |
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Mark J. Lema, M.D., Ph.D. Editor
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Propofol, remifentanil, sevoflurane, esmolol, desflurane, rocuronium,
midazolam, flumazenil, naloxone and laryngeal mask airways (LMAs)
have now become the new "regional anesthetics and techniques."
These drugs and devices, of course, do not actually provide regional
insensibility to pain. However, their ultrarapid pharmacology
allow for minute-to-minute control of general anesthesia. Consequently,
sicker, older patients can reliably be induced, maintained and
reawakened so as to advance the operating room schedule efficiently.
Thus, the traditional benefits of using regional techniques –
safety, comfort and analgesic prolongation – have been neutralized
for lesser invasive surgery cases by these newer agents.
In the early 1900s, when death from general anesthesia was 1:500
procedures, the application of regional blocks could save lives
and maintain homeostasis. Anesthesia has evolved beyond Kaplan-Meyer
survival curves to fast-tracking patients after cardiac surgery,
largely due to physician anesthesia, safer drugs and improved
monitoring. The extra time needed for performing the block or
the added risk of neural trauma, headache, hypotension, etc.,
may seem unjustifiable (except for resident training). Moreover,
with an increasing number of academic groups forced to adopt an
exclusive clinical practice paradigm, their goals now shift away
from educational benefit to time efficiency. Without clear-cut
indications to employ neuraxial blockade, pent-sux-tube (now Versed-prop-LMA)
techniques have dominated operating room anesthetics.
There are still active regional anesthesia programs. However,
with pain practices siphoning off operating room faculty, many
who were originally interested in regional blocks have evolved
into pain specialists. In future years, fewer peripheral, plexus,
spinal and epidural blocks will be routinely performed by the
"less interested in regional anesthesia" faculty. There
is a distinct risk that these techniques will no longer be taught
to residents. After all, does not the aphorism warn, "Use
it or lose it?"
As the current Vice-President of the American Society of Regional
Anesthesia and Pain Medicine, I am concerned about the Society's
decreasing membership and about the marked decrease in clinical
studies involving regional anesthesia being performed at U.S.
universities. Conversely, I also have witnessed regional anesthesia
thriving in Europe, where more than 800 people attended the Spanish
Society of Regional Anaesthesia's Annual Meeting, and more than
2,000 physicians participated in the World Congress of Regional
Anaesthesia in June 2002. What does the rest of the world know
that we in the United States do not?
Numerous studies suggest that regional techniques produce better
outcomes postoperatively with respect to blood loss, thromboses,
cardiovascular stability and analgesic relief. Often, sicker and
older patients undergoing major orthopedic and vascular surgery
greatly benefit from neuraxial techniques. Indeed, I would suspect
that the majority of blocks currently performed in the United
States are on this type of patient. However, is there any benefit
to spending additional time in the operating room or holding area,
possibly delaying surgery, to insert an epidural catheter for
a hysterectomy in a healthy 40-year-old woman? Is it really safer
to provide an interscalene block for a shoulder repair in a 25-year-old
male? With the pressure of improving case turnover, the absence
of academic incentives and the use of much safer anesthetics,
fewer physicians will see a distinct advantage in using blocks
over general anesthesia, perhaps even in sicker patients.
Regional anesthesia, however, is not yet moribund. With the discovery
of new acute pain receptors and pain pathways, undertreated pain
in the perioperative period can have long-term deleterious effects.
A study by Perkins and Kehlet1 revealed
that there may be an alarmingly high incidence of long-term postoperative
pain after routine cholecystectomies (60 percent) and herniorrhaphies
(37 percent). Woolf and Chong postulated almost 10 years ago:
"(Analgesic) therapy limited to the pre- and intraoperative
periods alone may be insufficient… because the inflammatory
reaction … postoperatively could induce central sensitization,
even if it had been prevented during the operation." 2
With an explosion of research data coming forth delineating mechanisms
for an acute-pain/chronic-pain continuum, a change in our roles
in holding areas or preoperative testing centers could mitigate
some long-term pain syndromes from developing. Anesthesiologists
again have the opportunity to create a paradigm shift to improve
conventional surgical care. Safer nonsteroidal anti-inflammatory
drugs (coxibs), use of local anesthetic blocks (or wound infiltration),
gentle surgical technique and postoperative nutritional support
have been shown to restore function sooner and with minimal pain.3,4,5
It is now possible to develop perioperative protocols that minimize
peripheral and central nociceptive sensitization throughout the
entire surgical experience, greatly improving comfort and hastening
convalescence.
Even though medicine is in the midst of a crisis, surgeons and
anesthesiologists can easily work together planning a perioperative
course that seeks to minimize long-term postoperative pain syndromes.
We are fooling ourselves if we believe that everything is fine
when the patient leaves the postanesthesia care unit pain-free.
We have only assured that the patient did not feel pain on our
watch. We do not often know if the surgical team will embrace
an aggressive analgesic regimen to continue suppressing the development
of second-order pain. By establishing protocols that prioritize
perioperative analgesia right into the patient's home, surgical
(and anesthesia) comfort and care improves – with the added
benefit of fewer long-term pain conditions occurring.
Let us not be too complacent by thinking that we no longer have
major areas to improve in anesthesia practice. After all, just
because everything seems all right, it does not mean that nothing
will go wrong.
– M.J.L
References:
1. Perkins FM, Kehlet H. Chronic
pain as an outcome of surgery: A review of predictive factors.
Anesthesiology. 2000; 93(4):1123-1133.
2. Woolf CJ, Chong MS. Pre-emptive analgesia:
Treating postoperative pain by preventing the establishment of
central sensitization. Anesth Analg. 1993; 77(2):362-379.
3. Barratt SM, Smith RC, Kee AJ, et al. Multimodal
analgesia and intravenous nutrition preserves total body protein
following major upper gastrointestinal surgery. Reg Anesth Pain
Med. 2002; 27(1):15-22.
4. Carli F, Lattermann R, Schricker T. Epidural
analgesia and postoperative lipid metabolism: Stable isotope studies
during a fasted/fed state. Reg Anesth Pain Med. 2002; 27(1):6-8.
5. Basse L, Raskov H, Jakobson H, et al. Accelerated
postoperative recovery programme after colonic resection improves
physical performance, pulmonary function and body composition.
Br J Surg. 2002; 89(4):446-453.
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