Adelaide Frolics

The Adelaide ANZCA ASM played like the regional anaesthesia empire strikes back. The regional enthusiasts gave some acknowledgment that RA contributes little to reducing serious adverse outcomes and they dismissed the significance of one in a few thousand chance of bad sequelae. However they derided "naffing confidence intervals", showed a picture of a satisfied fat American after a sciatic nerve block and one of the speakers made the alarming revelation that she was turned on by a successful peripheral block- well if that's what it takes to bed an anaesthetist....

Therese Horlocker continued her message about anticoagulants and regional anaesthesia. My impression of her view is that it is mostly a matter of careful timing, but this month's (June 06) BJA reveals that ceasing antiplatelet therapy perioperatively greatly increases the risk of a perioperative cardiac event. And with more diabetes, more coronary stenting and more use of clopidogrel for secondary prevention I think we will be increasingly presented with patients on antiplatelet therapy. It is hard to see how ceasing this therapy to allow neuraxial blocks will increase the overall benefit, particularly if the surgery can be reasonably attempted with the antiplatelet drugs on-board.

She also gave a bit about preexisting neurological disease and RA. The “double-crush phenomenon” occurs when an insult (such as lignocaine or a needle contact) to an already affected nerve has a synergistic negative effect. Multiple sclerosis is well known as disease that may be susceptible to the effects of local anaesthetics and the possible direct nerve trauma of a needle. Despite the hypothetical, Therese's Mayo Clinic has a reassuring case series of RA and MS. But if you don't need to do it, do you need to do it? Perhaps so in obstetric cases; should we consider that for MS cases we only use dilute bupivacaine for labour, concentrated epidural ropivacaine for CS, and avoid spinal doses (at least large doses) and epidural lignocaine and adrenaline?