ARE SPINAL ANESTHESIA AND INTERSCALENE BLOCKS REALLY NOT EFFECTIVE?
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- Опубликовано: 13 сен 2023
- Take a front-row seat as I tackle the pressing debates surrounding Spinal Anesthesia vs. General for hip fracture surgery, discuss the complications of Interscalene Block and the effectiveness of interscalene catheters. Fresh from the ESRA WORLD conference in Paris in September 2023, I bring insights straight from the leaders in Regional Anesthesia. Join me as I unpack the latest findings from RAPM and discuss why certain stances might be more hindering than helping Regional Anesthesia.
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Medicine is an ever-changing science. As new research and clinical experience broaden, changes in treatment and drug therapy are required. The authors and publishers have checked with sources believed to be reliable in efforts to provide accurate information within the available or accepted standards of care. However, given the possibility of human error or changes in medical practice, neither the authors nor the publisher, nor any other party involved in the preparation of this platform warrants that the information contained herein is in every aspect accurate or complete, and they disclaim all responsibility for any errors or omissions for the results obtained from the use of the information contained in this work. Readers are advised to confirm the information contained herein with other sources. For example, readers are advised to check the product information of each drug mentioned, and that any information contained on NYSORA's RUclips channel is accurate.
i see a great benefits from spinal in elderly with hip fractures.
I would like to have studies supporting this rather than other doctors saying they also think this way ;)
Greetings. The literature re: spinal is here: ruclips.net/video/zbTM30lgsLk/видео.html. THe literature re: Interscalane Catheters is in the the current video. Thank you for watching!
We should carry out studies that are led by experts in regional anesthesia: perhaps these authors are not experienced enough in clinical practice but are more experienced in papers, abstracts and statistics: I know many cases were the authors are respected for their knowledge and when it comes to skills they dont quite live up to the challenge. We should pursue a balance between clinical knowledge and clinical skills. And we know were our knowledge is really tested: in the trenches of the OR, ICU and ER.
Great feedback. Case in point - the methodology of various studies is so versatile in the absence of standardization in regional anesthesia that it is difficult to compare studies or reproduce the results with so many techniques and protocols (or lack thereof) variations.
You really hit the point.
Post operative cognitive decline is a huge concern after GA, especially in the frail hip fx population. Regional anesthesia in addition to all its other benefits helps lessen this problem. Thank you for bringing this to our attention and for your advocacy Dr. Hadzic!
There are no data to support your claim. Post-operative cognitive decline is a significant problem following hip fracture surgery regardless of anesthetic technique.
Large studies shows that there is no difference in postoperative cognitive decline between GA and regional or spinal anesthesia in the frail hip fx population...
Thank you for being the sane voice among the rabble rousers.
Hi Deepak. Thanks for watching! Love the term: "Rabble-rouser" : an individual who stirs up the passions or prejudices of the public, typically for his or her own agenda, often causing chaos or unrest. Rabble-rousers intentionally provoke others, especially crowds, into action by appealing to emotions, prejudices, or biases. Could I be interpreted as a rabble-rouser with this video? ;) Greetings
Nah..... I should rephrase my statement. Rabble rousers are those who are coming up with these new statistics. You are not a rabble rouser. We who have practised RA for most of our working careers know that incidence of complications in an experienced hand is neglible / very very rare. None of these new publications will change the minds of an experienced RA practitioner. However, when a bright resident comes to you and wants to discuss the latest research, I will have to work harder to put my practice across. Similarly, if a surgeon mentions the latest research and recommendations, I will have difficulty proving my position. These are small irritations. No big deal. This will not hit us. But this will definitely impact the way youngsters think. And of course, this is useful armour for those who are forever finding faults with RA. @@nysoravideo
Hmmm... Anesthesiologists complaining about General Anesthesia ? Equivalency is a great thing, it means clinicians can choose what is best for patients in their context. Perioperative care has improved significantly over the years such that outcomes may not be significantly different. Also some issues are sufficiently complex that mode of anesthesia is unlikely to have a significant impact, example cognitive dysfunction.The same issues plague intensive care trials.
I think he has problems with they are discreting regional on international lvl and it will affect pt and surgeons pressure on choice of anesthesia of MD.
Indian. Spinal is god of anesthesia. Most of procedures below umbilics is under spinal in hemodinamic stable pt. Even abdominal surgery are done under spinal if surgeons are fast.
Dr Hadzic, I need no convincing. Regional anesthesia is indispensable. But perhaps it would be better to take a closer look at these studies and find out why these conclusions were reached?
All this is true Very nice video thank you....!
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Dr. Hadzic, on what grounds is the journal going against well established and evidence based doctrine?
Also, You seem to REALLY dislike adjuvants to local anesthetics and are in favour of liposomal bupivacaine. 😊
Hi! 1) There is a lot of literature on the advantages of spinal over general anesthesia. This video explains why and cites much more relevant literature. studio.ruclips.net/user/videozbTM30lgsLk/edit 2) Interscalene complications and lack fo Catheters analgesic benefit - a quick PubMed search should be sufficient to answer. Likewise, anyone who practices Interscalene Blocks - and catheters clinically, knows first hand that the complications rate reported in RAPM is not possible. If indeed it was 34%, no one would be practicing interscalene. 3) Additives - do not work well. Exparel does - I have received it 3x as a patient, and can attest to the efficacy. Greetings and thanks for watching!
Thank you for bringing light to the subject. I have witnessed multiple accounts of gaslighting when it comes to regional anaesthesia.
Thank you for watching and providing the feedback. Can you describe a case or two of the gaslighting you witnessed? Thank you in advance!
@@nysoravideo One was concerning needing a spinal, and the answer was no. The only reason given was lack of evidence?
But the worst of it is having to explain to different health professionals what the basic physiology of a block is and why it can work so well. What I assumed was basic knowledge-shutting the nerve endings and increasing vasodilation.
I think many of the points you make are valid and backed up by evidence however every technique is only as good as the practitioner performing it. Hypotension during surgery for hip fracture is probably the real long term determinant rather than general vs spinal. The same goes for interscalene brachial plexus block which has got a higher complication rate than other brachial plexus approaches but is a great option for shoulder surgery. I love and deliver regional anaesthesia every single day for nearly all my patients and if I have to give a subjective opinion: spinal for hip fractures is my go-to option. Thank you for your informative videos.
Even though I agree with what Dr Hadzic says here, the only thing he gives to support it are expert opinions. We need science so we can stand against opposition to regional anesthesia.
Greetings and thank you for watching! For Interscalene blocks re: complications and efficacy of catheter - no need to do further studies - anyone who does them - sees the safety and the benefits as day and night! Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, Mariano ER, Johnson RL, Hargett MJ, Lee BH, Wendel P, Brouillette M, Go G, Kim SJ, Baaklini L, Wetmore D, Hong G, Goto R, Jivanelli B, Argyra E, Barrington MJ, Borgeat A, De Andres J, Elkassabany NM, Gautier PE, Gerner P, Gonzalez Della Valle A, Goytizolo E, Kessler P, Kopp SL, Lavand'Homme P, MacLean CH, Mantilla CB, MacIsaac D, McLawhorn A, Neal JM, Parks M, Parvizi J, Pichler L, Poeran J, Poultsides LA, Sites BD, Stundner O, Sun EC, Viscusi ER, Votta-Velis EG, Wu CL, Ya Deau JT, Sharrock NE. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. Br J Anaesth. 2019 Sep;123(3):269-287. doi: 10.1016/j.bja.2019.05.042. Epub 2019 Jul 24. PMID: 31351590; PMCID: PMC7678169.
@@nysoravideo great... a list of doctor and a 2019 article. I usually work at Ortho cases. I usually do block my patients, for analgesia or as anesthetics technique.
But this is not a solid argument to support my practice. Those are just names and an article...
@@nysoravideo even more, this are the conclusions from the ICAROS study:
Conclusions: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation.
I do believe that this is closer to the truth, based on what I have seen after 40 years as an anesthesiologist. I learn a lot from Dr. Hadzic and respect him a lot, but he seems to have an overt bias and agenda. @@xabisinganora5362
In Medicine there is always the fear of "fooling ourselves" (e.g. statins end heart disease, ulcers are caused by stress, high carb diets prevent obesity) ... I might die on this hill... Regional Anesthesia has profound and observable advantages when practiced by well-trained physicians. Ultrasound Machines do not make MD's competent in Regional... they are tools to hone/improve your skills... if you're diligent. There ex ist too many studies and life-experiences to seriously refute the better outcomes, improved mental cognition, fewer side effects of well managed Regional Anesth... but RAPM's Editorials WILL BE judged by Non-Practitioners of the Regional Arts(Insurance companies, Administrators, Governments, and ever Surgeons) ... It's not that RAPM shouldn't publish negative opinions, but only in the context of what is being claimed... Isolated & non-contextualized articles provide fodder to those who have agendas... Our agenda should be truth. RAPM's behaviour has me scratching my head.
Spot on! Do you foresee a pushback in your practice?
Maybe to search somewhere else… were regional anethesia is the only way to get things done! Maybe “underdeveloped” contries were RA have been the only choice for ages back!
It might help to educate those believing In this view to make a video showing benefits and success rates and outlining clinical studies favouring regional blocks, especially spinal Anastasia.
Teşekkürler.
Thank u Dr hadzic
@@chns3909 Thank you for watching! Greetings!
Doing a interscalene Block a posterior to anterior approach on a single shot block with a stimulator the only way to go or can you do anterior to posterior with No ultrasound only stimulator? Is anterior to posterior a safer approach without ultrasound guidance or mapping?
This video would be exceptionally more convincing if any evidence, other than anecdotal reports, were provided. Regional anesthesia can be invaluable, but polemics given without evidence are hardly worthwhile.
Thank you for watching Melting! One of the points in the video is that the articles. I am mentioning are challenging decades-established regional anesthesia techniques. THere is plethora of articles documenting their efficacy. And frankly, needing to provide that evidence would give the video a sense that I am defending these techniques. As is, it simply ridiculous that they are challenged in RAPM, the journal that has published the seminal work documenting their efficacy. Greetings!
We dont need to reinvent the wheel. There are multple studies out there highlighting the superiority of SP over GA in certian patinet populations eg. the frail elderly patient with a hip fracture.
SA is better than GA only For cesarean secions - we should be more objective - I did a lot of GA (with LMA) For hip fracture and It is More safe - i have Better control over BP What is crucial. The degree and How large is spinal blockade are often unpredictible and always assiciated with hypotension. Those patients have always comorbidity - e.g. aortic stenosis - we cannot even know about that before SĄ and the consequences can kill patients. Regional anestesia is great but must be done very often. In other casea can be dangerous.
Let's take this example. A 95 year old, cachectic patient with a hip fracture, and history of CHF is scheduled for surgery. Would you choose low-dose Spinal or General anesthesia? Greetings
@@nysoravideo the first choice is still SA here, but I wouldn"t very stubnorn in doing this kind of anesthesia. Every movement connected with trials of doing SA (usually "difficult backbone) causes pain in patients - its not comfortable and often trial is failded. My teatcher of anesthesia said that SĄ is For not very ill people. So when I see that SA would be difficult, last longer, patient's history is uncompleted or he/she sufferes from great pain - I choose GA.
Spinal with Sedation Propofol Tiva for Orthopedic and urology Surgery
All this is true, but I think that regional can be overused, especially amongst those with a vested pecuniary interest in doing as much regional as possible.
Brilliant comment! DO you see this trend in YOUR practice: Enthusiasm for new techniques, especially when they are published journals, can sometimes lead to overuse or premature widespread adoption before long-term efficacy and safety profiles are fully understood. Several factors can contribute to this phenomenon:
1. Early Enthusiasm: When new regional anesthesia techniques are introduced, there can be excitement about potential benefits, which might drive early and broad adoption.
2. Academic Pressure: Clinicians, especially those in academic settings, may feel compelled to try and adopt the latest techniques to stay at the forefront of their field.
3. Peer Influence: As colleagues begin using and discussing new techniques, there can be peer pressure to incorporate these practices.
4. Patient Demand: Occasionally, patients become aware of new techniques (through online resources, articles, or word of mouth) and might request them specifically.
5. Publication Bias: Journals might have a bias toward publishing positive results. This can give an overly optimistic view of a new technique, leading to its overuse.
6. Training and Workshops: Commercial interests, like pharmaceutical and medical device companies, might promote training or workshops for new techniques, sometimes before there's robust evidence of their superiority over existing methods.
However, it's worth noting that many anesthesiologists and pain medicine specialists are cautious in their approach. They often wait for consistent evidence before adopting a new technique as standard practice. Professional organizations, guidelines, and consensus statements should play a crucial role in ensuring that only techniques with sufficient evidence get recommended as standard care.
The spinal/GA for hip fractures has already caused a noticable change in my experience. Traditionally, Senior House Officers (SHO) would start their anaesthetic exposure by being attached to the anaesthetic registrars in acute orthopaedic theatre and would get alot of spinal experience before arriving at my institution as introductory registrars. One of them told me recently that they had done essentially no spinals for neck of femur fracture as their previous hospital just GA them all. So they were learning spinals during obstetrics.
Very insightful feedback. And if a leading journal in RAPM publishes editorials supporting the recent Neuman's NEJM study - which is not applicable to typical clinical practice - you can expect even more pushback on spinal, to the detriments of patients and education. A hypothesis where eventually there will be no critical mass of educators, is not far-fetched. Therefore, my gripe with RAPM's editorial direction is that the Journal should have an advocacy position and help standardization of regional anesthesia, and not drop napalm bombs. While the controversial papers may get some transient traction and help with the impact factor, on the long run - it will damage the field, and prove the hypothesis above. Greetings
Strong albeit expert opinion does not easily trump science. Studies need to be of higher quality and this can only be achieved by pooling limited resources. I am a strong advocate for regional anaesthesia but am not convinced that spinal anaesthesia has superiority over GA for hip fractures - the science simply doesn't support that stance. A GA with an ETT is preferable in BCIS situations and in the prevention of aspiration. In contrast an effective continuous regional infusion for analgesia in shoulder surgery is simply better as the pharmaco-physiological response dictates less pain and hardly needs extensive studies to prove this rather obvious outcome benefit - - but that's just my opinion 😉
4:58 my response to this would be - it takes the same amount of time to perform spinal anesthesia and to wake up the patient after general anesthesia. If it’s the same surgeon for multiple procedures in the same OR, no matter the anesthesia type, they’re gonna have to wait 10-15 minutes.
Do not forget the fact that spinal anesthesia can be done outside the operating room, as is 100% the case at NYSORA. Greetings
Shock and awe. ✊
Greetings from Marine Hadzic in the fight for Regional Anesthesia! Thank you for watching. Sir!
why so much clickbait recently?
All feedback is good. Actually - the point of this video is to raise the awareness about the "CLICKBAIT" direction of RAPM as of late. But the video itself goes pretty deep in honestly outlining the potential dangers to the subspecialty with disruptive publications that challenge the well established value of regional anesthesia. Would greatly appreciate your open view of which parts of the video(s) you perceive as clickbait. Greetings to you and your colleagues!
Zero science