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One of the oldest controversies in our specialty is the choice of regional vs. general anesthesia. Almost everyone has an opinion regarding which is preferable but even after extensively reviewing the literature it is easy to see that the controversy continues. For the vascular surgery patient who often has concurrent cardiac, pulmonary, and other systemic disease, the choice of anesthetic and postoperative analgesia technique is an important consideration.

At the most recent Annual Meeting of the SCA, we used an audience polling system that allowed the anonymous response from all individuals attending the session "Regional vs. General Anesthesia for Vascular Surgery." The audience was polled on anesthetic preference before and after the session. For both lower extremity and aortic surgery, there was a pre-session preference towards regional anesthesia and regional supplemented general anesthesia, respectively. After the session there was a "rightward shift" in the audience response (see figure) indicating that attending the session decreased the tendency to use regional anesthesia. The studies presented in the session that likely influenced preference were the trials by first authors Tuman,¹ Christopherson,² Baron,³ Bode,⁴ and Bois⁵ that showed minimal or no difference in cardiac morbidity. Some of the "rightward shift" in preference (against regional anesthesia) may also reflect the risks of epidural anesthesia/analgesia in the presence of heparin. The recommendations in a recent review by Horlocker⁶ add another dimension of medical-legal thinking about the risks of spinal/epidural hematoma. After the session there remained a bias towards regional anesthesia for lower extremity vascular surgery which may reflect the studies by Tuman¹ and Christopherson² demonstrating improved graft patency and a lower incidence of reoperation. Isn't it amazing that choice of anesthetic technique can improve surgical outcome?

In conclusion, there is a preference towards regional anesthesia for vascular surgical procedures among SCA meeting attendees. If the session at the 1999 Annual Meeting truly had an impact on practice, this would be a decreased tendency towards choosing regional anesthesia. We were able to measure this change in preference using the audience polling system. Audience polling is not only a useful data gathering tool but also provides a unique educational experience that enhances the value of our Annual Meeting.

References

1. Tuman KJ, McCarthy RJ, March RJ, Delaria GA, Patel RV, Ivankovich AD: Effects of epidural anesthesia and analgesia on coagulation and outcome after major vascular surgery. Anesth Analg 1991; 73:696-704

2. Christopherson R, Beattie C, Frank SM, Norris EJ, Meinert CL, Gottlieb SO, Yates H, Rock P, Parker SD, Perler BA, Williams GM: Perioperative morbidity in patients randomized to epidural or general anesthesia for lower extremity vascular surgery. Anesthesiology 1993; 79:422-434

3. Baron JF, Bertrand M, Barre E, Godet G, Mundler O, Coriat P, Viars P: Combined epidural and general versus general anesthesia for abdominal aortic surgery. Anesthesiology 1991; 75:611-618

4. Bode RH, Lewis KP, Zarich SW, Pierce ET: Cardiac outcome after peripheral vascular surgery: Comparison of general and regional anesthesia. Anesthesiology 1996; 84:3-13

5. Bois S, Couture P, Boudrault D, Lacombe P, Fugere F, Girard D, Nadeau N: Epidural analgesia and intravenous patient-controlled analgesia result in similar rates of postoperative myocardial ischemia after aortic surgery. Anesth Analg 1997; 85:1233-1239

6. Horlocker TT, Heit JA: Low molecular weight heparin: Biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management. Anesth Analg 1997; 85:874-885

Steven M. Frank, M.D.

Johns Hopkins Medicine

Baltimore, MD

Editor's Note: High bars to the left on the top two graphs indicate that respondents "agree" that regional anesthesia is good. High bars to the left on the lower graphs indicate "agreement" that the session changed their minds. Thus, a "shift" on the lower graphs would seem to indicate that the respondents still prefer regional anesthesia.