Funding: Health Foundation, ESVS

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 aboveLA 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 ?

• 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 comparedGA v Local infiltrationGA v regional nerve blockGA with and without regional nerve block

• No clear benefit established !MASTER study Lancet 2002; 359; 1276-82BMJ Rodgers 2000; 321: 1493 (also in bandolier)Lancet 2008; 372:562-569Best 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