ESRA Newsletter Journal Club

ESRA UPDATES journal club invites leading experts in (regional) anesthesia to select one (or more) article(s) which for him/her were/are important, interesting or changed his/her clinical practice. This choice can be a general big randomized study but can also be very personal. For this edition our choice went to Dr Paul Kessler.

Dr. Paul Kessler is a distinguished anesthesiologist renowned for his expertise in perioperative care and innovative approaches to anesthesia. With an extensive career marked by clinical excellence, Dr. Kessler has dedicated himself to advancing patient safety, pain management, and the integration of cutting-edge techniques in anesthetic practice. He has contributed significantly to the scientific literature, is a sought-after speaker at national and international conferences, and actively mentors the next generation of anesthesiologists.

Paul Kessler M.D. Ph.D.

Senior Consultant
Anaesthesiology, Intensive Care Medicine and Pain Therapy
University Hospital Frankfurt, Germany

First of all, I would like to mention an older article from 2013, which was published as an e-letter in the British Journal of Anaesthesia by Axel Sauter et al, Br J Anaesth, e-letter, 2013. In it, he describes a US-guided subcostal lumbar plexus block, better known as the Shamrock technique. Immediately after the publication, I have only used this technique since then, as it has a higher success rate and fewer complications than the other two lumbar plexus techniques, the paramedian transverse approach (Kirchmair L et al, Anesth Analg 2002; 94: 706 –10) or the longitudinal parasagittal approach (Karmakar MK et al, Br J Anaesth. 2008; 100: 533-7).
For me, this is the most fascinating US-guided block. In no other block is the cannula so far away from the US probe, sometimes over 10 cm or more in obese patients, and yet the cannula is clearly visible in the US image. This is due to the perpendicular needle guidance. However, since it is a deep block, nerve stimulation should always be used in adults for safety reasons. Overall, ultrasound has made the lumbar plexus block much safer than using nerve stimulation alone.

Unfortunately, the US-guided lumbar plexus block is no longer very popular. This is because today, after major hip and knee surgery, early mobilization is also required in addition to good analgesia. This is difficult to achieve with the lumbar plexus block. Therefore, its use today remains limited to complex hip, thigh and knee operations after which early mobilization is not carried out. For several reasons, however, operations on children with complex hip dysplasia remain an excellent area of ​​application, especially since nerve stimulation is not required and a linear transducer can be used due to the shallow depth of the lumbar plexus.

The endless publications and discussions about the best anaesthesia procedure for major hip surgery have ultimately changed my clinical practice.

The ESRA newsletter has also reported on this topic in the past. I would just like to explain the statistical problem using two publications.
Firstly, there is the prospective randomized multicenter study by Neuman et al, which found no difference in 60-day mortality after hip surgery: spinal 3.9% and general anaesthesia 4.1% (N Engl J Med 2021;385:2025-35). On the other hand, there are several meta-analyses or registry data with several hundred thousand patients that show that the postoperative outcome is better after neuraxial procedures than after general anaesthesia, including Memtsoudis SG et al, Br J Anaesth. 2019; 123(3): 269-287. Due to the many shortcomings of meta-analyses or reviews, we can only speak of a positive association between spinal anesthesia and hip surgery. Nevertheless, the highly significant differences in favor of the neuraxial procedures indicate a positive influence of these procedures.

«Based on the Neuman study, which found a difference in mortality between spinal and general anesthesia of 0.2%, approximately 100,000 patients would have to be recruited to show differences.»

It will be impossible to prove these positive effects of neuraxial procedures for hip surgery in randomized controlled trials. Based on the Neuman study, which found a difference in mortality between spinal and general anesthesia of 0.2%, approximately 100,000 patients would have to be recruited to show differences. Such a prospective study has not yet existed and will not be carried out in the future for cost reasons.

So we have to make do with what we have. So where is the truth? Should we believe underpowered prospective studies or the results of registry data and meta-analyses?
My personal opinion is that if a sufficiently high number of patients were included, the advantages of spinal anesthesia could also be demonstrated in prospective studies. Therefore, I have changed my practice to favor spinal anesthesia for hip surgery.

References

1. Axel Sauter et al, Br J Anaesth, e-letter, 2013.
2. Kirchmair L et al, Anesth Analg 2002;94: 706 –10
3. Karmakar MK et al, Br J Anaesth. 2008 Apr;100(4):533-7
4. Neuman MD et al, N Engl J Med. 2021 Nov 25;385(22):2025-2035
5. Memtsoudis SG et al, Br J Anaesth. 2019; 123(3): 269-287