Quality and outcome in anaesthesia

Anaesthesia can be a thankless task. Get it right and others take all the plaudits. Get it wrong and you find yourself in the limelight for all the wrong reasons. Nowhere is this more true than in high risk areas such as paediatric cardiac anaesthesia, just one area tackled at the Royal College of Anaesthetists’ recent 2012 anniversary meeting. The two-day conference covered a broad range of issues facing anaesthetists, from avoiding errors, improving outcome and training, through to litigation and consent. The final two sessions, ‘controversies in quality care’ and ‘high risk surgery’ offered much food for thought.

Controversies in quality care

The use of epidurals in anaesthesia is always controversial. “Such a technique can produce a degree of patient comfort unmatched by any other analgesic technique, but wider use is inhibited by concerns about major complications,” said Professor Tony Wildsmith, a former Council member of the Royal College of Anaesthetists (RCoA) and foundation professor of anaesthesia, University of Dundee (1995-2007). Prof. Wildsmith looked at the use of an epidural block as the analgesic component of a balanced anaesthetic for surgery to the trunk, with the epidural continuing to provide analgesia post-operatively. “Concerns stem from reports of relatively high incidences of complications, notably epidural haematoma in the US and epidural abscess in the UK, although reviews from other countries were less worrying,” said Prof. Wildsmith. An RCoA audit of major complications of central nerve block, resulting in either death or permanent harm, revealed statistics of between 1 in 5,000 and 1 in 10,000 patients. “These are relatively reassuring figures,” said Prof. Wildsmith, “although each case is a source of great distress to both patient and anaesthetist.” Prof. Wildsmith went on to stress that the incidence of major sequelae relating to other analgesic techniques is far less defined and may be greater; the figures are small compared with the overall incidence of mortality and morbidity after surgery; and very often the complications are associated with failures in management and these should be avoidable. The benefits are high quality pain control, as a visit to any labour or recovery ward will testify. Some reviews of the ‘regional versus general’ literature show evidence of a reduction in morbidity and mortality, while others remain inconclusive. “The way out of this maze is by a very careful risk-benefit analysis which recognises that continuous epidural block is for severe post-operative pain in high-risk patients after major surgery,” said Prof. Wildsmith. The benefits then outweigh the risks, but only when those risks are minimised by ensuring the following: