Regional vs General Anaesthesia – Back and Forth

Regional vs General Anaesthesia – Back and Forth

  • Issue 71

Gabriel M. Gurman, Chief Editor
gurman@bgu.ac.il

Once again, I find myself thinking about the history of my profession, which in good measure is my own story. I started my training almost 60 years ago, when the first generation of anaesthesiologists, immediately after WW II, struggled with the not-so-fit drugs and equipment, which permanently put patient safety in jeopardy. Little by little, with a lot of enthusiasm and initiative, and with the help of industry, modern anaesthesia reached a level which today offers the patient the best methods of maintaining homeostasis during surgery, and at the same time ameliorates his/her suffering in the perioperative period.

One of the modern approaches regarding these aims is the combined use of various anaesthesia methods – general, regional, and peripheral nerve blocks. To the young anaesthesiologist this reality seems to be natural. Each of the methods has advantages and drawbacks, so what could be more logical than to combine them and thus avoid the untoward effects of each of them? But the road of achieving this understanding and applying it in routine practice was a long one.

One could just hope that after the famous use of ether as a general anaesthetic in the year 1846, by the not less famous Bill Morton, this drug would become used in every single operating room. But the reality was completely different. General anaesthesia at that time proved to be a danger for the patient. Neither chloroform nor cyclopropane (does anybody still remember these two inhalatory drugs?!) produced better results and the percentage of deaths on the operating table did not decrease. Cardiorespiratory depression was the rule, and the physician’s means to combat this dreadful complication was rather sparse and completely ineffective.
The need for an alternative was obvious, and soon locoregional anaesthesia found an important role and place in the daily activity of the operating room. A quick look into the short history of anaesthesia, such as that published last year in our Newsletter by Prof George Litarczek, would find the main milestones on the way to using this kind of method in the past.

It started with frozen limbs for amputation during Napoleon’s war and went on with the extensive use of cocaine for local analgesia by Koller, an eye surgeon, in 1884; then for so-called “trunk anaesthesia” for peripheral nerves by Corning; the first cocaine subarachnoid administration by Bier in 1898 (who also used intravenous local anaesthesia for the first time); and, finally, epidural anaesthesia in the second decade of the 20th century by Pages.

The use of locoregional anaesthesia conquered the operating rooms, but not only there. The first spinal anaesthesia for labour was performed in 1900. New local anaesthetic drugs showed up and they have been used for every single technique – infiltration, spinal, and even epidural.

So, WW I found the field of anaesthesia limited only to those procedures and it is easy to understand today that that situation could not contribute to the development of modern surgery and did not provide a solution for more extensive procedures, such as thoracic surgery or neurosurgery.

The revolution started in different places in the civilized world. The need for more efficient methods was evident and clinicians looked for new ideas which could provide better conditions for work in the operating room. One after the other, the first (primitive!) anaesthesia machines have been introduced in daily practice, together with the endotracheal intubation and CO2 absorbers. General anaesthesia started the fight for conquering the operating theatres, but nothing was perfect. The introduction of curare by Griffith and artificial ventilation in order to prevent respiratory depression represented immense progress in the fight for preserving the cardiorespiratory function during surgery.

The aftermath of WW II created a proper scientific and clinical atmosphere for the development of general anaesthesia. The 1952 polio epidemics, with so many cases of respiratory muscles paralysis and the need for artificially assisting ventilation represented a real boost in the right direction, and mechanical ventilation became the method of choice for preserving the normal gas exchange during surgery.
But rather curiously, locoregional anaesthesia was almost forgotten. The spectacular use of new inhalatory drugs like halothane and the appearance of new and better-handled muscle relaxants, seemed to entirely satisfy the clinicians belonging to the new (and recognized!) medical speciality. More than this, almost nobody paid attention to the fact that epidural analgesia for labour became state-of-the-art in many maternity and obstetrical departments. Tens of years of practicing locoregional anaesthesia remained isolated somewhere at the periphery of surgical practice and used only in those places that could not afford to have anaesthesiologists and modern drugs and equipment for performing general anaesthesia.

It is not my intention to present here a full image of the history of our profession. I only thought that a short review of the stages passed by anaesthesia as a profession would help the reader, and especially the young ones, to understand the real miracle we are witnessing today in our current practice.

In the last decades the combination between general anaesthesia and locoregional techniques became the rule. Clinical studies provided undisputable evidence that this combination creates much better conditions for the surgeon, prevents dangerous over-dosage, keeps the homeostasis in normal limits, and also offers better patient satisfaction.

More than this, the use of locoregional analgesia during surgery was gradually extended to the immediate postoperative period, taking care of the postoperative pain and contributing to a more rapid recovery by permitting a quick mobilisation and natural feeding of the patient.

For the new generations of anaesthesiologists this rather banal description of our routine activity could be seen as an obsolete and futile one. What could be more natural than abdominal surgery performed under general anaesthesia with endotracheal intubation and mechanical ventilation, to which epidural analgesia was added and continued after surgery, until the moment postoperative pain could be handled by minor per os analgesics?

But the road to this excellent achievement was long and difficult with a lot of steps back and forth, with a lot of incertitude and failures.

The very seldom neurologic damage produced by spinal or epidural anaesthesia created an unsustained feeling that these techniques are not suitable for daily practice. For years “total” spinal anaesthesia was considered an obstacle in the way of generalizing the practice of epidural anaesthesia for surgery. The patient wanted to be asleep during surgery and it was rather difficult to convince him or her about the simple possibility of adding a benzodiazepine for alleviating his psychological stress on the operating table. The average surgeon did not have the necessary patience to wait outside the operating room until the regional anaesthesia reached full effect. But all those impediments have all been overcome.

More than this, the techniques of peripheral nerve blocks became in the last years the state-of-the-art in the operating rooms, being added to any other anaesthesia method, or even being used as a sole technique for suitable surgical procedures. The introduction of ultrasound guidance in the daily practice opened a tremendous new option, since it offers a much safer technique and a diminished danger of nerve damage.

So, it seems that the decision to dedicate the 2017 ESA Focus Meeting on Perioperative Medicine (Tel Aviv, 9–10 November) to regional anaesthesia and analgesia comes as recognition of the fact that this old/new field of our profession became part of our daily practice.

The combined use of general and regional anaesthesia is a reality of our days. It needs a lot of theoretical knowledge and also individual development of skills and experience. But today nobody could dare to oppose this very positive trend, for the benefit of the patient and his/her own safety.

An old saying mentioned the fact that our work in the operating theatre covers three main objectives: safety for the patient, comfort for the surgeon, and prevention of coronary vasoconstriction for the anaesthesiologist. Personally, after so many years of clinical activity, I have no doubt that the routine combination of various anaesthesia techniques entirely fulfils these aims.