when not to block
TRANSCRIPT
When not to block William Harrop-Griffiths
Consultant Anaesthetist, St Mary’s Hospital, London Honorary Senior Lecturer, Imperial College, London
St Mary’s Hospital, Paddington, London
St Mary’s Hospital, Paddington, London
When not to block
William Harrop-Griffiths Consultant Anaesthetist, St Mary’s Hospital, London Honorary Senior Lecturer, Imperial College, London
“There are no patchy blocks with propofol!”
The non-regional anaesthetist
“I wouldn’t do a regional anaesthetic on someone who uses their arm to earn a living”
The non-regional anaesthetist
The non-regional anaesthetist
For them, every day of their life is a time not to block
For those of us who know how to block
When not to block
Contra-indications
Regional Anaesthesia William Harrop-Griffiths
Consultant Anaesthetist, St Mary’s Hospital, London Honorary Senior Lecturer, Imperial College, London
Contra-indications to
Contra-indications
Absolute
Relative
Absolute contra-indications
• Patient refusal
• Local sepsis
• Allergy
Relative contra-indications
• Spinal
• Specific
• Generic
Spinal contraindications • Hypovolaemia
• Cardiac valvular stenosis
• Spinal abnormalities - tumour, spina bifida, surgery
• Includes blocks that sometimes become spinal
• Epidural
• Paravertebral
• Lumbar plexus
Specific situations
• Try not to block both phrenic nerves
• Try not to block three or more limbs
Generic relative contraindications • Paediatric, combative and demented patients
• Systemic sepsis
• Abnormality of anatomy
• Abnormality of coagulation
• Abnormality of nerves
• Where analgesia might mask the pain of ischaemia caused by compartment syndrome
Generic relative contraindications • Paediatric, combative and demented patients
• Systemic sepsis
• Abnormality of anatomy
• Abnormality of coagulation
• Abnormality of nerves
• Where analgesia might mask the pain of ischaemia caused by compartment syndrome
Generic relative contraindications • Paediatric, combative and demented patients
• Systemic sepsis
• Abnormality of anatomy
• Abnormality of coagulation
• Abnormality of nerves
• Where analgesia might mask the pain of ischaemia caused by compartment syndrome
Summary • There is very little evidence available (in
the form of hard data) to inform practice
• This is both good and bad
• Good because it gives sensible clinicians licence to do what is sensible
• Bad because it makes the ground fertile for “expert opinion”
Systemic sepsis
Question
• Is a PNB safer than a CNB in the septic patients?
• No real answer but my answer is:
• I would rather have an infected sciatic nerve than purulent meningitis
• But on balance, I would rather have neither
Summary • There is little hard evidence to inform
practice
• The risk is low
• There are some who will avoid RA in patients with evidence of systemic sepsis
• Modify the risk by giving antibiotics
• If RA offers particular advantage, the patient with capacity may agree to take a (very slightly increased) risk
Coagulopathy
Don’t too much about the exact
numbers
stress
Obstetric anaesthetist asked to do an epidural
12:01 h Time after last prophylactic dose of enoxaparin
stress
11:59 h
Obstetric anaesthetist asked to do an epidural Time after last prophylactic dose of enoxaparin
stress
Risk is not binary
It is a spectrum
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 100 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 99 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 98 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 97 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 96 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 95 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 94 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 93 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 92 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 91 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 90 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 89 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 88 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 87 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 86 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 85 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 84 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 83 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 82 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 81 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 80 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 79 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 78 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 77 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 76 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 75 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 74 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 73 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 72 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 71 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 70 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective, infra-umbilical abdominal surgery
• Would you be happy to do a spinal?
Platelets 69 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Mild NSAID-sensitive asthma
• Elective LSCS
• Would you be happy to do a spinal?
Platelets 69 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Morbidly obese
• Mild NSAID-sensitive asthma
• Elective LSCS
• Would you be happy to do a spinal?
Platelets 69 x 109.l-1
The platelet game • 32-year-old ASA 2 patient
• Morbidly obese
• Known difficult intubation
• Mild NSAID-sensitive asthma
• Elective LSCS
• Would you be happy to do a spinal?
Platelets 69 x 109.l-1
The platelet game
Platelets 49 x 109.l-1
• 32-year-old ASA 2 patient
• Morbidly obese
• Known difficult intubation
• Mild NSAID-sensitive asthma
• Elective LSCS
• Would you be happy to do a spinal?
Other games
• INR game
• Hours after the last dose of LMWH game
• Days since the last dose of clopidogrel game
Messages
• Coagulopathy really is a relative contraindication
• Fixed thresholds can and should be flexible
Question
• Most guidelines are about neuraxial blocks
• What about PNBs?
• Are they safer?
PNBs and coagulopathy
• Only 26 reports of significant haemorrhagic complications of PNBs
• 13 patients had normal coagulation
• Majority were deep blocks or superficial perivascular blocks
• One death: clopidogrel + lumbar plexus block
Haematological conditions
One A4 side of advice
• The majority of haematological abnormalities of coagulation are known in advance of anaesthetic intervention
• Most involve a deficiency in a particular cell line, clotting factor or combination of clotting factors
Haematological conditions
• Therefore, solution is usually easy • For instance... • If the patient suffers from a lack of Factor
XXiXa (Dubrovnik) • Give the patient a couple of bags of Factor
XXiXa (Dubrovnik) before the block • Simples! • Advice - talk to a haematologist • If you can find one
Haematological conditions
Summary • There is little hard evidence to inform
practice
• The risk is low
• Some will avoid RA in patients with abnormal coagulation
• Modify risk by treating the coagulopathy or using different blocks if possible
• If RA offers particular advantage, the patient with capacity may agree to take a (very slightly increased) risk
Abnormality of nerves
• Should RA be used in patients with pre-existing neurological disorders?
Epidurals and MS No - it might affect
the abnormal nerves
It’s fine but pregnancy can make
MS worse and you don’t want to get the blame
There is no evidence whatsoever that it will affect
the MS - carry on!
Summary
• There are case reports of abnormal nerve function getting worse after RA
• But no hard evidence
• Familiar?
“Patients with pre-existing neurological disease may bat increased risk of new or worsening injury regardles of anaesthetic technique. When RA is thought to be appropriate for these patienmodifying the technique may minimise risk. Based on a moderate amount of animal data, such modifications may include using a less potent LA, min vasoconstrictors. Limited human data neither confirm nor refute these modifications”
Summary • There is little hard evidence to inform practice
• The risk is low
• Some will avoid RA in patients with neurological conditions
• Modify risk by using lower concentrations of LA if possible and avoiding adrenaline
• If RA offers particular advantage, the patient with capacity may agree to take a (very slightly increased) risk
Compartment syndrome
• A clash of two cultures
• Anaesthetists and orthopaedic surgeons
• Why do anaesthetists tend to take an instant dislike to orthopaedic surgeons they meet?
• Orthopods can rely on a substantial body of published material
CASE REPORT I had a patient who got compartment syndrome and didn’t do very well. They had an epidural so it must be th anaesthetist’s fault. Bashem-All F, et al Bone & Hammer 2011; 13: 12-15
CASE REPORT I had a patient who got compartment syndrome and didn’t do very well. They had a nerve block so it must be the anaesthetist’s fault. Thumpit R, et al Bone & Hammer 2012; 14: 22-25
CASE REPORT I had a patient who got compartment syndrome and didn’t do very well. They had an anaesthetic of some sort so it must be the anaesthetist’s fault. Blame-Game P, et al Bone & Hammer 2013; 15: 232-235
Literature survey • Publications referring to influence of
analgesic technique on diagnosis
• 28 case reports/case series
• Epidural: 23
• PCA: 3
• PNB: 2
Blame the analgesia
• Case series of 4 patients with tibial fractures
• PCA morphine blamed
• All had 0.5 - 1.0 mg morphine per hour
Analgesia to blame?
• Some cases where epidural provided postoperative “anaesthesia”
• PNBs not implicated
Conclusions • Pain is an unreliable symptom
• There are no RCTs or outcome-based comparative trials
• “There is no convincing evidence that PCA or RA delay the the diagnosis of compartment syndrome provided patients are adequately monitored”
What is the answer?
• Can you use RA in patients at risk from compartment syndrome?
• Sadly, there are entrenched views
It is never my fault that my operations go wrong!
My patients with tibial fractures must not have blocks!
What is the answer? • Do not adopt entrenched views
• Communicate with the surgeon
• PNBs or epidurals with dilute LAs can give good analgesia without obscuring signs of compartment syndrome (probably)
• Discuss with the patient as well as surgeon!
Summary • There is little hard evidence to inform practice
• The risk is low
• Some will avoid RA in patients at risk of compartment syndrome
• Modify risk by using lower concentrations of LA
• If RA offers particular advantage, the patient with capacity may agree to take a (very slightly increased) risk
Regional anaesthesia • Involves taking risks sometimes for the overall
benefit of patients
• And taking decisions on the basis of clinical judgement rather than hard data
• Because there are no hard data
• In a world in which protocols and guidelines are increasingly controlling us
• This amount of clinical freedom is fun
The End
La fin
Das ende
Fine
Thank you
Merci
Danke
Grazie