“Future directions in regional anaesthesia: not just for the cognoscenti
T. Selak
First published: 05 September 2019
doi.org
Cited by: 1
No external funding or competing interests declared.
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I read with interest Turbitt, Mariano and El‐Boghdadly's recent editorial 1. Regional anaesthesia has numerous potential benefits including opioid minimisation, high quality analgesia and avoidance of general anaesthesia risks. The recent proliferation of affordable ultrasound machines with improved image quality has led to the development of many ultrasound‐guided regional anaesthesia blocks. These blocks aim to further improve patient care, but the authors argue that some so‐called ‘new’ techniques are in fact previously used methods relying on ‘anatomical minutiae’ using unique nomenclature to differentiate them. This unnecessary complexity can alienate the non‐expert and can lead to block avoidance. Some patients therefore have no access to regional anaesthesia because their anaesthetist perceives modern techniques as insurmountably difficult. The authors argue that regionalists should focus on a simplification process, whereby the most effective blocks are selected from the plethora of options and these chosen few are actively moved from the bespoke into the mainstream. Turbitt et al. argue that anaesthesia as a specialty should aim to promote ‘a few blocks for the many’ rather than ‘many blocks for the few’.
The authors published a short list of high‐value basic blocks that they believe should be core for all anaesthetists and they go on to list other advanced blocks that can be used by experts. Predictably, the published list has triggered robust discussion amongst regional experts on social media 2. This commentary, while informative and entertaining, displays one of the downsides of discussions within groups of enthusiasts. In our quest to provide the best technical care for patients, have we placed sufficient emphasis on patient‐centred care? The holistic anaesthetist cares about the emotional wellbeing of the patient, as well as technical aspects of care.
A recent prospective observational study of upper limb surgery under regional or general anaesthesia assessed patient satisfaction postoperatively 3. The study was limited by a small sample size and lack of randomisation and therefore risks uncorrected confounders.
However, the results are worthy of review and may be surprising to some anaesthetists. There was a statistically significant decrease in satisfaction for patients who had regional anaesthesia (32.1% not fully satisfied) compared with those who had general anaesthesia (5.5% not fully satisfied). The most common reasons for dissatisfaction were insufficient anaesthesia prior to surgery and discomfort with an insensate and uncontrollable arm postoperatively. Additionally, Droog et al. noted that lower pain scores did not necessarily lead to higher satisfaction scores.
De Andres et al. noted that patients’ experience of regional anaesthesia was the least evaluated area of anaesthetic practice 4. This seems to have remained unchanged 24 years later. A Google ScholarTM search of ‘regional anaesthesia’ retrieved 2860 results on the 8th July 2019. Adding the term ‘satisfaction’ to the title search reduced this to 23 results. An identical PubMedTM search produces a ratio of 1045:3. In practice, anaesthetists care deeply about the experience of their patients, but this is not reflected in the journals. We cannot assume to know what patients want, we need to ask them.
Whilst I applaud the insight of Turbitt et al. to propose an edit of regional anaesthesia techniques in order to simplify, be inclusive and facilitate broader use, future regional anaesthesia work should, however, include a greater emphasis on patient preferences and satisfaction to inform selection of the most appropriate anaesthetic techniques, whether regional or general.”
