GALA: an international multicentre randomised trial comparing general anaesthesia versus local anaesthesia for carotid surgery

Background: Patients who have severe narrowing at or near the origin of the internal carotid artery as a result of atherosclerosis have a high risk of ischaemic stroke ipsilateral to the arterial lesion. Previous trials have shown that carotid endarterectomy improves long-term outcomes, particularly when performed soon after a prior transient ischaemic attack or mild ischaemic stroke. However, complications may occur during or soon after surgery, the most serious of which is stroke, which can be fatal. It has been suggested that performing the operation under local anaesthesia, rather than general anaesthesia, may be safer. Therefore, a prospective, randomised trial of local versus general anaesthesia for carotid endarterectomy was proposed to determine whether type of anaesthesia influences peri-operative morbidity and mortality, quality of life and longer term outcome in terms of stroke-free survival. Methods/design: A two-arm, parallel group, multicentre randomised controlled trial with a recruitment target of 5000 patients. For entry into the study, in the opinion of the responsible clinician, the patient requiring an endarterectomy must be suitable for either local or general anaesthesia, and have no clear indication for either type. All patients with symptomatic or asymptomatic internal carotid stenosis for whom open surgery is advised are eligible. There is no upper age limit. Exclusion criteria are: no informed consent; definite preference for local or general anaesthetic by the clinician or patient; patient unlikely to be able to co-operate with awake testing during local anaesthesia; patient requiring simultaneous bilateral carotid endarterectomy; carotid endarterectomy combined with another operation such as coronary bypass surgery; and, the patient has been randomised into the trial previously. Patients are randomised to local or general anaesthesia by the central trial office. The primary outcome is the proportion of patients alive, stroke free ( including retinal infarction) and without myocardial infarction 30 days post-surgery. Secondary outcomes include the proportion of patients alive and stroke free at one year; health related quality of life at 30 days; surgical adverse events, re-operation and re-admission rates; the relative cost of the two methods of anaesthesia; length of stay and intensive and high dependency bed occupancy

The Role of Infiltrative Local Anaesthesia in Thyroidectomy

Background: General anaesthesia is the anaesthetic agent of choice during thyroidectomy, however, recent reports there is a role for local anaesthesia. This study reports on the experience of thyroidectomy performed under infiltrative local anaesthesia in a rural surgical setting.Methods: This was a review of patients who underwent thyroidectomy during a surgical camp. We included the bio data of the patients, anaesthesia used, duration of surgery, immediate complications and duration of stay. Patients underwent either general or infiltrative local anaesthesia.Results: Out of seven patients undergoing surgery, three were performed under infiltrative local anaesthesia. The average age for all the patients was 37.43 +/- 5.3 years and there was no statistical difference in the mean age between patients who underwent infiltrative anaesthesia and those who underwent general anaesthesia. We noted one immediate transient difficulty in breathing in a patient who underwent general anaesthesia. The average length of stay was 2 days for local anaesthesia group and 2.25 days for general anaesthesia.Conclusions: There was no difference between the two groups either on biodata or outcome measures. Local anaesthesia is a safe alternative to general anaesthesia for patients undergoing thyroid surgery

The applications of sub-Tenon's anaesthesia for canine ophthalmic surgery : a thesis presented in fulfilment of the requirements for the degree of Master of Veterinary Science (MVSc) at Massey University, Manawatu, New Zealand

Sub-Tenon's anaesthesia is an indispensable anaesthetic technique in human ophthalmic surgery. It produces highly effective regional anaesthesia and has a significantly lower complication rate than the previously used peribulbar and retrobulbar injections. Although this technique has potential application to veterinary ophthalmology it has not yet been reported in clinical cases. This thesis reviews the literature that references local anaesthesia for ocular surgery in human and veterinary ophthalmology. A sub-Tenon's block technique that was specifically developed for use in dogs is also described. This technique is assessed with a prospective controlled clinical study testing this technique across a variety of ocular surgeries including enucleation, intrascleral prosthesis, keratectomy with a third eyelid flap and cataract surgery. The effect of sub-Tenon's anaesthesia on specific parameters was recorded and compared to the controls such as; globe position and rotation, pupillary dilation, general anaesthetic monitoring parameters, intraocular pressure, vitreal expansion and post-operative pain scores. Analysis of these parameters has indicated that sub-Tenon's anaesthesia was an effective option for controlling post-operative pain when used in conjunction with systemic analgesics and was an excellent alternative to systemic neuromuscular blockade for canine cataract surgery

Regional anaesthesia in cancer surgery: an update

Anaesthetic techniques can influence the cellular immune system and affect long term outcome. Cancer surgery itself and general anaesthetics, especially opioids, suppress immunity and therefore promote metastases. Regional anaesthesia attenuates the immunosuppressive effect of surgery. Local anaesthetics, contrary to opioids, stimulate the activity of natural killer (NK) cells during the perioperative period. All techniques of regional anaesthesia are very useful and applicable in cancer surgery, either for the anaesthesia itself or for the treatment of postoperative pain. The relationship between regional anaesthesia and cancer recurrence is one of the most interesting topics in anaesthesia today, but we must wait the results of prospective trials before definitive conclusions

Regional Femoral Nerve Block Combined with Local Anaesthesia in Day Surgery for Varicose Veins

AbstractThree anaesthetic techniques are commonly used in surgery of varicose veins: general anaesthesia, central nerve block and tumescent anaesthesia. In this report we evaluate the efficacy and safety of another method – regional femoral nerve block with additional local anaesthesia. We report the early postoperative outcome in a group of 56 patients managed using this type of anaesthesia. In all cases removal of all incompetent saphenous trunks and varices was accomplished without any operative complication. Two cases of wound infection occurred postoperatively and in three patients skin abrasions were caused by bandages. 62% of patients are asymptomatic 2 months after surgery. We have found this anaesthetic method to be safe, efficient, easy and quick to perform. It offers an alternative to tumescent or general anaesthesia for day surgery in patients with varicose veins

Anaesthesia for Ophthalmic Procedures in a Teaching Hospital

Objectives: To study the pattern of anaesthesia for ophthalmic procedures in order to improve the scheduling of cases in the ophthalmic operating room. Methods: The surgical register of the operating room from August 01, 1999 to July 31, 2004 was examined, to document the types of procedure, timing of surgery (elective or emergency), methods of anaesthesia, and involvement of anaesthesia personnel. Results: A total of 970 patients (506 males, 464 females) had ophthalmic surgery in the five-year period under review. General anaesthesia was employed for 119 (12.3%) patients and regional anaesthesia for 851 (87.7%). 400 patients had their procedures on ambulatory basis (LA = 397, GA = 3). Local blocks were the favoured technique for both the outpatient and inpatient settings. Cataract extraction, repair of corneal/scleral/conjunctival/lid lacerations, excision biopsy, trabeculectomy and evisceration were the leading indications. General anaesthesia was the more commonly employed anaesthetic technique in younger patients and for emergency ophthalmic procedures. The general anaesthesia was administered by the registrar and senior registrar grades of anaesthetists. Conclusion: The study shows that the use of general anaesthesia appeared largely restricted to paediatric patients and emergency situations. However, evolving techniques – like sub-tenon block, total intravenous anaesthesia (TIVA), monitored anaesthesia care – should be encouraged. Keywords: ophthalmic anaesthesia, paediatric anaesthesia, regional blocks, outcomeNigerian Journal of Ophthalmology Vol. 16 (1) 2008: pp. 1-

Local anaesthesia efficacy as postoperative analgesia for open shoulder instability surgery. a prospective randomised controlled study

Background and objectives: The aim of present study was to evaluate for the first time, the clinical effect of local anaesthetic infiltration as postoperative analgesia in open shoulder surgery for anterior-inferior instability. The comparison of the local infiltration and interscalenic brachial plexus block to a control group test the local anaesthetic efficacy in this surgery. Methods: 78 patients scheduled for open shoulder surgery were enrolled and randomly assigned to one of three groups: local infiltration anaesthesia (LIA), interscalenic brachial plexus block (IBPB) and control (C). All patients received standardized general anaesthesia and all injections were performed with the same dose and volume of anaesthetic. The number boluses delivered by a PCA pump applied at the end of surgery and the visual analogue score (VAS) at 0, 2, 4, 6, 12, 18 and 24 hours after intervention were recorded. A patient satisfaction score was also assessed. Results: Mean bolus consumption of the rescue analgesic, compared to C, was significantly less both in the LIA and IBPB groups (P<0.05). The IBPB group showed VAS scores that were significantly better than C group at all time points (P<0.05). The VAS scores for LIA group were clinically comparable to IBPB, and only at the 2 and 6 hours, postoperative time points there were no significant differences found in respect to the C group. IBPB and LIA showed comparable patient satisfaction scores. Conclusion: The local anaesthetic infiltration as postoperative analgesia appears to be a clinically valid alternative, statistically comparable to IBPB, with no clinical meaningful adverse effects

Anaesthetic Management of Ischemic Heart Disease patient for Total Abdominal Hysterectomy under Epidural Anaesthesia and Analgesia

Anaesthetic management of cardiac patient’s coming for non cardiac surgery has always been challenging. Goal of anaesthesia management is to keep myocardial oxygen supply greater than demand to avoid ischemia. Choice of anaesthesia has been general anaesthesia (GA) by achieving the goals, in order to prevent ischemia intra and post operatively in cardiac patient coming for non cardiac surgery. In this case report anaesthetic implications included assessment of cardio vascular status of the patient pre operatively with selection of epidural anaesthesia and analgesia technique. Incremental doses of local anaesthetic (LA) were given keeping in mind, myocardial oxygen supply to be greater than demand to avoid ischemia. To the best of our knowledge, there have been only few case reports on epidural anaesthesia for ischemic heart disease (IHD) patient coming for non cardiac surgery. Hence we report a successful anaesthetic management of a patient with ischemic heart disease for total abdominal hysterectomy under epidural anaesthesia and analgesia

Spinal Anaesthetic Management in Paediatric Surgery

The first paediatric cases involving the use of spinal anaesthesia were published at the end of the nineteenth century. However, the technique did not receive much interest in paediatric anaesthesia until the 1980s. In the last three decades, paediatric spinal anaesthesia has received widespread approval as an alternative technique to general anaesthesia in school-/preschool-aged children, particularly in term and preterm neonates with high risk associated with general anaesthesia. The development of new and safer local anaesthetics mainly through better understanding of the pharmacokinetics and dynamics and dedicated paediatric tools are the keys to this success. Paediatric spinal anaesthesia is an easy and effective technique, and its high efficiency and safety are supported by the presence of numerous publications from the medical literature. However, it remains limited to situations in which general anaesthesia poses a major risk. Despite these advances, it is important to understand the correct technique and the anatomy of children at different ages. Also, the appropriate equipment, the pharmacokinetics and toxicities of local anaesthetics and the indications and complications of paediatric regional blocks should be well known. The goal of this chapter is to review and discuss some of these topics of paediatric spinal anaesthesia for paediatric surgery