Anatomy and Neuroscience - Theses
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ItemThe quality and safety of peripheral regional anesthesia( 2012)INTRODUCTION: Modern anesthesia care is thought to be extraordinarily safe related to the safety of general anesthesia. Many patients and anesthesiologists consider regional anesthesia to be an alternative anesthetic technique introducing additional risk. Perioperative adverse events are not systematically reported and epidemiological tools that measure the incidence of adverse events rarely exist. However, adverse events influence how our colleagues and the public view our specialty and the therapies we recommend. Therefore, obtaining reliable incidence data on complications is of paramount importance. Measuring a broad range of quality outcomes is important for patient consent and clinical decision-making. The objectives of this thesis were to determine the quality and safety of peripheral regional anesthesia during a period in which regional anesthesia was evolving because of increased utilization of peripheral and ultrasound-guided techniques. METHODS: The methodology involving 21 hospitals was a clinical registry, where data on routine peripheral nerve block practice was entered in an online interface. Data was collected from January 2006 to May 2012 inclusive. A research infrastructure and registry were developed to facilitate capture of all patients who received peripheral nerve blockade so as to determine the incidence of infrequently occurring complications. Clinical effectiveness and patient-rated outcomes were developed. The study protocol included systematic postoperative patient contact. The registry data was then interrogated to determine practice patterns, clinical effectiveness, patient-rated outcomes and complications. RESULTS: Ultrasound-guidance was the primary technique utilized in 63% and 83% of nerve blocks between 2006-08 and 2008-12 respectively. Upper extremity, trunk, paravertebral and lower extremity blocks were utilized in 29, 15, 4 and 48% of cases respectively. Ropivacaine was utilized in 87% of cases with a median dosage of 1.5 milligram/kg. Patients reported being satisfied or completely satisfied with information provided to them and interaction with their anesthesiologist in 93% of cases. Pain scores in the immediate postoperative period were consistently low, however 53% of patients reported moderate or severe pain on block recession. The incidences of nerve block related events per 1000 PNB (95% CI) [denominator] were: inadvertent vascular puncture, 4.0 (3.2 – 4.8.) [25,336]; paresthesia, 11.8 (10.5 – 13.2.) [25,336]; wrong-site blocks, 0.28 (0.10 – 0.60) [21,646]; respiratory compromise, 3.4 (1.72 – 6.16) [3197]; pneumothorax, 0.98 (0.12 – 3.53) [2049]; local anesthetic systemic toxicity, 0.87 (0.54 - 1.3) and long term nerve block related nerve injury, 0.30 (0.11 – 0.67). Patients with postoperative neurologic features were most likely to have a cause unrelated to peripheral nerve blockade. Ultrasound guidance was associated with a reduced risk of local anesthetic toxicity. CONCLUSION: This registry was an effective epidemiological tool that collected data on large numbers of patients during routine clinical care. This project has demonstrated that serious adverse events associated with peripheral nerve block are infrequent or rare. When this outcome is combined with favourable effectiveness outcomes the conclusion of this thesis is that the overall quality and safety of peripheral nerve blockade is high.