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Regional Anesthesia

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Ushmi Patel

on 28 October 2015

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Transcript of Regional Anesthesia

The preferred type of regional anesthesia largely depends on the duration and nature of the surgery being performed as well as other patient-specific factors. The most commonly utilized types of block are:
Supraclavicular block
Axillary block
Interscalene block
Infraclavicular block
Bier block
Rescue block

Colorectal Surgery
Nerve Anatomy & Pathophysiology
Types of Anesthesia
Anesthetic Agents
Regional Anesthesia
Anesthetic Surgeries & Blocks
Orthopedic Surgery
Obstetric Surgery
Continuous Peripheral Nerve Block - cPNB
Peripheral Nerve Block (PNB)
Considerations for Regional vs. General Anesthesia Clinical Trials
Regional Anesthesia vs. General Anesthesia
Population Assessment

Sensation is transmitted via propagation of electrical impulses
Propagation occurs by alternating ion gradient across the nerve cell wall
In normal resting state, the nerve cell has a membrane potential of -70mV
The Na+ and K+ ATP pump maintains this resting state when the nerve cell is not stimulated
When stimulated, the Na+ ions rush in causing an increase in the membrane potential to a threshold level
Once there is enough stimulation to pass the threshold, the membrane reaches levels of +35mV and above
After reaching the peak, Na+ channels close and K+ channels open
The nerve cell returns to its resting state

Nerve Pathophysiology
Anesthetic Agents
July 2014
Review of Journal Articles/Clinical Trials
Ambulatory Breast Tumor Resection
Arthroscopic Shoulder Surgery (Beach Chair Position)
Bariatric Surgery
Cardiothoracic Surgery
Colorectal Surgery
Distal Radius Fracture Fixation
Joint Arthroplasty
Major Lower Extremity Amputation
Outpatient Hand Surgery
Postanesthesia Care Unit Length of Stay (PACU-LOS)
Total Knee Arthroplasty
Risks vs. Benefits of Regional Anesthesia Summary


Inhaled through a breathing mask or tube, or administered through an intravenous line
A breathing tube may be inserted into the windpipe to maintain proper breathing during surgery

Numb only the portion of the body that will receive the surgical procedure

Injection of local anesthetic given in the area of nerves that provide feeling to that part of the body

Used for anesthesia and postoperative pain relief
Regional Anesthesia
Most commonly used for obstetric and orthopedic procedures

CENTRAL (Neuraxial)
Most frequently used
Spinal anesthesia (CSF) and epidural anesthesia

Numb the appropriate area of your body extremity (arm, leg, head) that requires surgery
Plexus Block and Single Nerve Block
Most frequently used:
Femoral nerve block
- injection in the leg region
Brachial plexus block
- injection in the arm and shoulder region
Using ultrasound or electrical stimulation to determine the optimal injection site
Used by itself or with conscious sedation
1. http://www.seanesthesiology.com/patients/types-of-anesthesia/regional-anesthesia.html
2. http://www.asra.com/patient-info-regional-anesthesia-and-analgesia-for-surgery.php 3.http://health.ucsd.edu/specialties/anes/Pages/regional-nerveblock.aspx 4. http://www.webmd.com/a-to-z-guides/epidural-and-spinal-anesthesia-topic-overview

Temporarily stops sense of pain in a particular area of the body
Can be administered via injection to the site for minor surgery

Patient remains conscious during a local anesthetic

Nalie Kernizan - Danielle McDonald - Kushal Patel - Ushmi Patel
Regional Anesthesia
Blocks & Surgeries
Axillary block
- hand, elbow or forearm surgery
Lumbar plexus block
- hip replacement surgery
Femoral block
- knee replacement and ACL reconstruction.
(not the back of knee)
surgeries for: anterior thigh,
, quadriceps tendon repair
Popliteal and Saphenous bloc
- fo
ot and ankle surgery
Ankle block
- foot surgery
Bier Block
- arm, wrist or forearm surgery
(short procedures < 40 mins)
Interscalene block
- shoulder surgery
Spinal block
- surgery lower half of your body
Infraclavicular Block
- wrist, forearm and elbow surgery
Cervical plexus block/cervical paravertebral block
- shoulder and upper neck surgery
Regional anesthesia is most commonly employed in the following procedures:

1. Orthopedic Surgery
A broad and diverse specialty encompassing the diagnosis, care, and treatment of complications involving the musculoskeletal syst
Examples include, but are not limited to, fractures, tendon ruptures, bone tumors, and total joint replacements.

2. Obstetric Surgery
A more focused specialty pertaining to childbirth
Includes cesarean sections (C-sections)

1. http://www.seanesthesiology.com/patients/types-of-anesthesia/regional-anesthesia.htm
2. http://orthoinfo.aaos.org/topic.cfm?topic=A00274
3. http://surgery.about.com/od/glossaryofsurgicalterms/g/ObstetricsSurge.htm

Review of Journal Articles/Clinical Trials
Colorectal Cancer Surgery
: Comparing Epidural-general anesthesia followed by epidural analgesia (EA) & Balanced general anesthesia followed by Pethidine Analgesia (Pethidine group)

- Epidural analgesia demonstrated:
better effectiveness
Fewer adverse events

profound sedation, nausea and vomiting occured more often in pethidine group
Pruritis was more common with EA
Pain scores
at rest and on coughing were
significantly better
in epidural analgesia group (p<0.05) during the day of surgery and first 3 POD
Better self- satisfaction
scores via Self-assessment manikin (SAM) in epidural analgesia group patients

There were no significant differences between the 2 groups in
respect to complications and postoperative hospital stay
Bariatric Surgery
Regional Anesthesia
RA reduces respiratory impairment, hemodynamic endangerment, and interference with the gastrointestinal tract:
Reduces risk of respiratory infections and thrombosis
Early alimentation and mobilization of the GI tract
superficial anatomic hallmarks are difficult to recognize
epidural local anesthetic dose must be decreased because intra-abdominal pressure dilates the epidural veins

General Anesthesia
Challenges: airway management, ventilation, & pharmacokinetics (liphophilic drugs have a great volume
of distribution and half-life)

Ambulatory Breast Tumor Resection
Orthopedic Surgery
Arthroscopic Shoulder Surgery
60 total patients
: 30 undergoing interscalene block (ISB) anesthesia + sedation w/ spontaneous ventilation
: 30 ISB + GA w/ mechanical ventilation
Treat cerebral desaturation events (CDEs), where cerebral oxygenation saturation (Scto2) decreased 20% from baseline awake values
55% Scto2 has been linked with organ dysfunction

Scto2 values lower than a threshold value of 55% was seen in 23.3% in the asleep group vs 3.3% in the awake group. (P= 0.52)
89 combined desaturation events were documented in the asleep vs 1 in the awake group (P < .0001)
RA + sedation had almost no cerebral desaturation
Avoidance of GA for patients in the beach chair position may reduce the risk of ischemic neurologic injury due to cerebral desaturation

Considerations for RA vs GA Clinical Trials
Any study seeking to evaluate the supremacy of one type of anesthesia over another would most likely be inherently
due to:
Lack of a standardized scoring system
that considers various patient parameters
institutional bias
Ethical dilemma of
randomizing study subjects
Difficulty of
defining reliable primary and secondary outcomes
difficulty in recruiting individuals
in the study

Regional anesthesia has been found to be marginally superior to general anesthesia in most studies, but the issue still remains open to debate

It is recommended that anesthesia should be tailored to individual patient requirements to optimize patient outcomes

Rashid RH, Shah AA, Shakoor, A, Nordin S. Hip Fracture Surgery: Does Type of Anesthesia Matter?. BioMed Research International. 2013
Primary Outcome Variable:
QoR (Quality of Recovery) : measured by QoR Questionnaire (QoR-27)
64 women were randomized - 33 undergoing PVB & propofol-based TIVA (PVB group)
31 undergoing general anesthesia (control group)
PVB group
Significantly higher QoR scores upon discharge and on postoperative day (POD) 2
a median of 15 points upon discharge
a median of 10.5 points on POD 2
Higher QoR scores on POD 4 (but difference did not reach
statistical significance)
Combination of ultrasound-guided PVBs and TIVA (PVB group) enhances the QoR and allows for the preservation of QoL compared with inhalation gas- and opioid-based GA in patients undergoing ambulatory breast tumor resection
Obstetric Surgery
Regional anesthesia, as opposed to general anesthesia, enables the mother to be alert and present throughout the process and also limits the amount of medication transmitted to the newborn
Typically involves epidural, spinal, or epidural-spinal combined surgery
Administered through an epidural catheter
With an epidural catheter in place, a smooth transition can be made to a caesarian section if need be by simply administering a stronger dose of the anesthetic
An epidural catheter can also be used post-surgically for recovery and management of pain
Quicker and more pronounced pain relief because of the direct administration of the local anesthetic into the spinal fluid

Additional benefits include: improved postoperative pain relief up to 48 hours after surgery; reduced PONV; and expedited PACU and hospital discharge
Peripheral Nerve Block

No patients in PVB group required conversion to sevoflurane-based GA, required admission for hospital stay, and there were no complications attributable to PVBs
perioperative pain management
pain management after trauma
acute postoperative pain management after major orthopedic and thoracic surgery
chronic pain
Better postoperative pain control than systemic patient-controlled analgesia (PCA)
Reduces the need for opioids by 40-70% and their related complications
Analgesia seen on postop Day 3
Single injection nerve block provides up to 12-24 hours of analgesia- “relatively short”
1.Chelly JE, Ghisi D, Fanelli A. Continuous peripheral nerve blocks in acute pain management. Br J Anaesth. (2010) 2010;105(Suppl 1):i86–96. [PubMed]
2. Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesthesia and Analgesia. 2006;102(1):248–257. [PubMed]
Image: http://www.raadvantages.com/advantages/how-patients-benefit/
Abdallah FW, Morgan PJ, Cil T, et al. Ultrasound-guided multilevel paravertebral blocks and total intravenous anesthesia improve the qualityofrecovery after ambulatory breast tumor resection. Anesthesiology;120:703-13,2014.
Earlier mobilization and functional recovery
Shortens hospital stay and rehabilitation center
Improves sleep
Decreases the frequency of unanticipated admissions and readmissions after same day surgery and their associated costs

Peripheral Nerve Block
Current practice mainly utilizes general anesthesia, regional anesthesia (primarily epidural and spinal), or a combination of both
Nerve Block

CABG (with cardiopulmonary bypass) with GA + thoracic epidural analgesic/anesthetic (TEAA):
fewer dysrhythmias
fewer pulmonary complications
shorter time to extubation in the intensive care unit postoperatively
better analgesia at rest and with activity

TEAA - ‘gold standard’ due to its superiority over systemic analgesia and the observed improvements in pulmonary function and outcomes
paravertebral and intercostal blockade nerve blocks and local anaesthetic infiltration are all described for thoracotomy postop pain
systemic review needed to confirm
Cardiothoracic Surgery
Concern with use of central neuraxial analgesia for CABG surgery is the potential for increased risk of spinal hematoma w/ heparin
incidence= 1:1,528
avoid CNB in coagulopathy

No differences in the rates of mortality or MI after coronary artery bypass grafting with central neuraxial analgesia

Indicated for surgical procedures requiring unilateral analgesia or anesthesia
Unilateral paravertebral blocks are
mmonly performed in breast surgery, thoracotomy, herniorrhaphy, open cholecystectomy, and open nephrectomy
Thoracic paravertebral blockade is an option for those who cannot undergo epidural analgesia
Approach Techniques include:
Loss of resistance
Nerve stimulation
Ultrasound guidance
Fluoroscopic guidance
Advancing the needle 1.5-2 cm beyond
Transverse process

Tziavrangos E, Schug SA (2006) Regional anaesthesia and perioperative outcome. Current opinion in anaesthesiology 19: 521–525 [PubMed]

2.Liu SS, Block BM, Wu CL. Effects of perioperative central neuraxial analgesia on outcome after coronary artery bypass surgery: a meta-analysis. Anesthesiology 2004;101:153–61
Liu S, Carpenter RL, Neal JM. Epidural anesthesia and analgesia. Their role in postoperative outcome. Anesthesiology. 1995;82:1474–1506.
Gastrointestinal and Colorectal Surgery
: Combined Lumbar Spinal & Thoracic High-Epidural RA

Patients demonstrated early postoperative recovery
With effective analgesia
No requirement for intubation
Particularly low frequency of respiratory complications
Lower morbidity and mortality rates
No negative effect on overall length of stay



Enhanced cost effectiveness
Less postoperative pain
Less nausea (not CNB)
Lower incidence of blood clots
Less blood loss
Less of a stress response by the body
Reduced mortality/morbidity
Minimal side effects (such as postoperative delirium - especially in elderly patients)
Avoidance of intubation or ventilation leads to improved outcomes
Regional anesthesia is particularly appealing to patients undergoing orthopedic procedures



More stable operative course
Shorter induction time

1. Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anesthesia improve outcome after total knee arthroplasty? Clin Orthop Relat Res. 2009;467:2379–2402.
2. S. C. Kettner, H. Willschke and P. Marhofer.Does regional anaesthesia really improve outcome? British Journal of Anaesthesia 107 (S1): i90–i95 (2
3. Rashid RH, Shah AA, Shakoor, A, Nordin S. Hip Fracture Surgery: Does Type of Anesthesia Matter?. BioMed Research International. 2013. doi:10.1155/2013/252356
4. M. D. Neuman, J. H. Silber, N. M. Elkassabany, J. M. Ludwig, and L. A. Fleisher, “Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults,” Anesthesiology, 117(1);72–92, 2012.
5.Liu SS, Strodtbeck WM, Richman JM, Wu CL: A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg 2005, 101:1634-1642

1.[Comparison of two different methods of analgesia. Postoperative course after colorectal cancer surgery]. [Lithuanian] Rimaitis K. Marchertiene I. Pavalkis D. Medicina (Kaunas). 39(2):129-37, 2003.
2. Combined Lumbar Spinal and Thoracic High-Epidural Regional Anesthesia as an Alternative to General Anesthesia for High-Risk Patients Undergoing Gastrointestinal and Colorectal Surgery. Skipworth J, Srilekha A, Raptis D, et al. World J Surg. 33:1809-1814, 2009.
Rare neurological injury- Vast majority of injury is temporary, and resolves over weeks to months
Rate of neurological complication after CNB is <0.04%
Rate of neurological injury after PNB is < 3%
Urinary retention after CNB is possible
Require additional performance time and technical skill
Incidence of ADRs varies by type
Increased induction time

Associated with early postoperative cognitive dysfunction (transient)
Postoperative deliriums
Longer operative duration

Distal Radius Fracture Fixation
Patients who undergo open treatment of distal radius fractures under regional anesthesia experience less pain & better wrist and finger range of motion (ROM) in the early postoperative period:
At 3 Months
- Improvement in wrist ROM with RA
Palmar flexion
Ulnar Deviation
- Finger ROM: significantly better in all digits (except the thumb) in RA patients
- Pain: significant improvement in RA
At 6 Months
- Continued improvement in:
Wrist ROM
Finger ROM
At 12 Months
- Pain scores and DASH scores were similar
- Majority of wrist ROM normalized
Wrist palmar and dorsal flexion maintained significant improvement
with RA
- Finger ROM: better in patients who
received RA
No significant difference in grip strength and no complications related to RA or GA
Nerve block decreases the number of pain impulses reaching the brain, lessens the amount of pain the patient experiences, provides better analgesia, and ultimately leads to better long-term outcome

Regional anesthesia improves outcome after distal radius fracture fixation over general anesthesia.Egol KA. Soojian MG. Walsh M. Katz J. Rosenberg AD. Paksima N.Journal of Orthopaedic Trauma. 26(9):545-9, 2012 Sep
Joint Arthroplasty

Tziavrangos E, Schug SA (2006) Regional anaesthesia and perioperative outcome. Current opinion in anaesthesiology 19: 521–525 [PubMed]
General anesthesia (GA) may be associated with increased
risk of early postoperative cognitive dysfunction
(transient effect not seen beyond 7 days)

Cerebral Oxygenation in Beach Chair position
Postanesthesia Care Unit Length of Stay
Major Lower Extremity Amputation
RESULTS: 30-day mortality is significantly higher in patients undergoing general anesthesia
Study population = 1365
Retrospective observational cohort study
Patient population heterogeneity makes generalizations difficult and inappropriate
Choice of anesthetic technique is a complex decision that depends on many factors beyond what was analyzed in the study
Nontraumatic major lower extremity amputation (MLEA): 8-32% 30-day mortality rate
Most common complication: cardiovascular
Patients classified in study into low-, intermediate-, and high-risk
GA: inhalational or IV
30-day mortality = 13.7%
RA: central or peripheral neuraxial block
30-day mortality = 9.3%
Matched retrospective study with 30,616 surgeries (prospective trials still needed)

Two cohorts:
RA with or without GA

No difference between those who received RA and those who did not
Compared to GA, RA was associated with a decreased PACU LOS
Patients who received RA were 78% more likely to be successfully discharged from the PACU compared to those who received GA only

: Regional anesthesia is favored when compared to general
anesthesia in an unselected population at a large tertiary-care
No difference/insufficient evidence between regional anesthesia (RA) and general anesthesia (GA):
Cardiovascular morbidity

Deep venous thrombosis (DVT) and pulmonary embolism
: no difference in incidence with chemical prophylaxis
Blood loss
Duration of surgery
Cognitive effects
: reduced pain scores and/or morphine consumption with RA compared to GA
Level I Evidence: epidural analgesia and single-injection femoral nerve block (FNB) were superior to systemic analgesia

Opioid-related adverse effects:
reduced effects in FNB, FNB + obturator block, FNB + sciatic block, continuous FNB, and epidural analgesia
All data measured and analyzed as secondary outcomes
Most prominent reduction in: nausea, vomiting, and sedation
Length of stay:
continuous FNB or FNB can reduce hospital stay by up to 1 day and/or the length of rehabilitation stay by up to 13 days
Only reported in one Level 1 and two Level 2 studies
Improved rehabilitation:
RA (continuous FNB, FNB, and epidural analgesia) improved rehabilitation compared with GA
Range of motion and ambulation improved by either continuous FNB or FNB

Total Knee Arthroplasty
Is regional anesthesia associated with reduced PACU length of stay?: A retrospective analysis from a tertiary medical center.Corey JM. Bulka CM. Ehrenfeld JM.Clinical Orthopaedics & Related Research. 472(5):1427-33, 2014 May
Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anesthesia improve outcome after total knee arthroplasty? Clin Orthop Relat Res. 2009;467:2379–2402

No Significant Differences between RA & GA
Carotid Endarterectomy
Anesthesia technique does not impact patient outcomes after carotid endarterectomy (but may influence overall cost of care)
Effect of anaesthetic technique on mortality following major lower extremity amputation: a propensity score-matched observational study.Khan SA. Qianyi RL. Liu C. Ng EL. Fook-Chong S. Tan MG.Anaesthesia. 68(6):612-20, 2013 Jun
Hip Fracture Surgery
Shorter operative duration with RA
No statistically significant differences (in rates of wound infections, LOS, postoperative complications, intraoperative blood loss, mortality) between the regional and general anesthesia groups

Percutaneous Nephrolithotomy (PCNL)
Study results showed supracostal PCNL performed with regional anesthesia has no evident advantages over PCNL performed with general anesthesia in PCNL patients

1. Regional versus general anesthesia for carotid endarterectomy: the American College of Surgeons National Surgical Quality Improvement Program perspective.Schechter MA. Shortell CK. Scarborough JE.Surgery. 152(3):309-14, 2012 Sep
2.Rashid RH, Shah AA, Shakoor, A, Nordin S. Hip Fracture Surgery: Does Type of Anesthesia Matter?. BioMed Research International. 2013
3.The feasibility of regional anesthesia in the percutaneous nephrolithotomy with supracostal approach and its comparison with general anesthesia.Moslemi MK. Mousavi-Bahar SH. Abedinzadeh M.Urolithiasis.41(1):53-7,2013 Feb
126 patients chose anesthesia: GA, IVRA (Bier Block), or Axillary Brachial Plexus Block (BPB)
Longer induction time seen in RA use (longest in BPB group)
Opioid Analgesics Use (P < 0.05)
GA: 85%
IVRA: 51%
BPB: 43%
N&V requiring antiemetic medication use (P <0.05)
GA: 62%
IVRA: 18%
BPB: 12%
PACU recovery time (P <0.05)
GA: 70±14 mins
IVRA: 45± 21mins (stat sig vs BPB and GA)
BPB: 63±32 mins
IVRA: lower anesthetic drug and equipment cost
Less demand on nursing time
Hospital cost savings 30% with IVRA vs GA
Outpatient Hand Surgery
Clinical Outcome and Cost Analysis

1.Chelly JE, Ghisi D, Fanelli A. Continuous peripheral nerve blocks in acute pain management. Br J Anaesth. (2010) 2010;105(Suppl 1):i86–96. [PubMed]
Image: Richman JM, Liu SS, Courpas G, et al. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesthesia and Analgesia. 2006;102(1):248–257. [PubMed]
1.Brull R, McCartney CJL, Chan VWS, El-Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. International Anesthesia Research Society. 104(4), 2007 Apr
3.Liu SS, Strodtbeck WM, Richman JM, Wu CL: A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg 2005, 101:1634-1642
4. http://www.nysora.com/updates/3106-neurologic-complications-of-peripheral-nerve-blocks.html
1. http://bariatrictimes.com/regional-anesthesia-for-bariatric-surgery/
2. http://virtue.ucdenver.edu/ManualFiles/AnesthesiaForBaraiatricSurgery.pdf

1. http://www.seanesthesiology.com/patients/controlling-pain-after-surgery/12-nerve-blocks.html
2. http://prc.coh.org/ComRegNB.pdf
4. http://www.seanesthesiology.com/patients/types-of-anesthesia/regional-anesthesia.html
V. W. S. Chan, P. W. H. Peng, Z. Kaszas et al., “A comparative study of general anesthesia, intravenous regional anesthesia, and axillary block for outpatient hand surgery: clinical outcome and cost analysis,”Anesthesia & Analgesia, vol. 93, no. 5, pp. 1181–1184, 2001
Colorectal Surgery
Neer Award 2012: cerebral oxygenation in the beach chair position: a prospective study on the effect of general anesthesia compared with regional anesthesia and sedation. Koh JL. Levin SD. Chehab EL. Murphy GS.Journal of Shoulder & Elbow Surgery. 22(10):1325-31, 2013 Oct.[Comparative Study. Journal Article]UI: 23571083
Complications are uncommon but include
local anesthetic toxicity
nerve injury
IV Regional Block/Anesthesia (Bier block)
Somnolence, incoherence, seizures, and cardiac arrest
Compartment syndrome
Longer acting anesthetics (e.g. bupivacaine) increase risk of systemic toxicity without any added efficacy

Has potential to cause the greatest number of side effects and complications.

Most side effects clear up within 24 hours or so. The most common ones are:
Sore throat (caused by the devices used to keep the airway open)
Drowsiness or feeling tired hours after surgery
Nausea and vomiting
Headache, dizziness, and vision problems
Damage to teeth (caused by airway devices)
Risk depends on several factors:
overall health
underlying medical conditions
current use of tobacco, alcohol, and drugs

1. Chelly JE, Ghisi D, Fanelli A. Continuous peripheral nerve blocks in acute pain management. Br J Anaesth. (2010) 2010;105(Suppl 1):i86–96. [PubMed]
2. http://www.uptodate.com/contents/overview-of-anesthesia-and-anesthetic-choices?source=search_result&search=regional+anesthesia&selectedTitle=1%7E150#H6
3. http://www.healthcommunities.com/before-after-surgery/complications-of-anesthesia.html
Patient Populations that Benefit
from Regional Anesthesia
Full-term pregnancy
The mother can be alert throughout the birthing process
Medication transfer to the fetus/newborn is relatively limited as compared to GA, which can cause cardio-respiratory depressant effects
Obstetric patients have higher rates of difficult and failed intubation as compared to non-obstetric patients
RA is preferred for mothers who are
morbidly obese
, have difficult airways, or have
cardiac conditions
that limit perfusion
Respiratory deficiency
RA is associated with less respiratory morbidity than GA, which can be correlated with endotracheal intubation
In-hospital mortality and incidence of pulmonary complications is lower with RA as compared with GA (6.8% vs 8.1%)
Elderly patients
RA remains the choice of anesthesia for older and
ailing patients

1. http://www.hopkinsmedicine.org/howard_county_general_hospital/services/mothers_and_babies/labor_delivery_and_recovery/obstetrics_epidural_spinal_anesthesia/
2. Australian & New Zealand Journal of Obstetrics & Gynaecology. 52(4):311-2, 2012 Aug
3. M. D. Neuman, J. H. Silber, N. M. Elkassabany, J. M. Ludwig, and L. A. Fleisher, “Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults,” Anesthesiology, 117(1);72–92, 2012.

QoR questionnaire can vary between 29 and 155. A 10 point score difference is considered clinically significant
- Postoperative cognitive dysfunction
Postoperative cognitive decline, delirium, or confusion
Excluding dementia

Assessment of postoperative cognitive dysfunction
Studies assessed postoperative cognitive dysfunction via:
Confusion Assessment Method
Diagnostic and Statistical Manual of Mental Disorders ( DSM-IV)
Studies assessed postoperative cognitive dysfunction via:
Mini Mental Status Examination (MMSE
Studies assessed for change via:
Wechsler Adult Intelligence Scale (WAIS)
Total Knee Arthroplasty
Ambulatory Breast Tumor Resection
1.Tziavrangos E, Schug SA (2006) Regional anaesthesia and perioperative outcome. Current opinion in anaesthesiology 19: 521–525 [PubMed]
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