#36918 Do we always need an anaesthesiologist in operating room for minor surgery under peripheral nerve block? – yes

Regional anaesthesia is well established as an integral part of perioperative care, providing excellent analgesia for a wide range of procedures. Advances in techniques including the widespread use of ultrasound, the advent of modern local anaesthetic drugs and improvements in monitoring have all contributed to enhanced safety for patients. Avoiding general anaesthesia and its associated adverse effects is a commonly cited benefit of regional anaesthesia. Many of the physiological parameters commonly affected, and thus carefully monitored, during a general anaesthetic are relatively unaffected by a peripheral nerve block. The administration of potent and, in inexperienced hands, dangerous drugs with adverse cardiovascular or respiratory effects is avoided, and ‘normal’ physiological homeostasis is broadly maintained. Patients are also in a position to report new symptoms as and when they arise, and by avoiding general anaesthesia the patient’s conscious level can act as an additional monitor for attending clinicians. Acknowledging this, there have been calls from regional anaesthesia societies to relax the requirement for an anaesthesiologist to be present in the theatre for surgery under peripheral nerve blockade.1 Major governing bodies have not wholly committed to such an initiative, with most still calling for the presence of trained anaesthesia personnel.2 3 The Association of Anaesthetists’ standards for monitoring during anaesthesia and recovery acknowledge that there may be ‘some situations’ where it may be acceptable.4 This perhaps reflects an appropriate reluctance to back this proposal. Patient Anxiety and Comfort Greater than 80% of patients report anxiety pre-operatively.5 Indeed, anxiety has been reported to be the most troubling aspect of the perioperative period for many patients, surpassing even pain.6 The process of anaesthesia is a significant source of concern for patients, and in some cases may be more psychologically distressing than the surgical procedure itself. Establishing a patient–anaesthesiologist relationship in the perioperative period is vital to reducing anxiety and is even more important in the context of patients undergoing awake surgery.7 Over the course of the patient’s theatre journey, the anaesthesiologist may identify specific sources of worry, gain important information about the patient’s wishes and concerns and may modify their anaesthetic plan to cater for this.8 This personalised approach to anxiety reduction may not be readily adopted by less specialised providers who may monitor, but not modify the anaesthetic technique independently. Having a named and familiar anaesthesiologist throughout the case provides continuity and may indeed be a source of comfort for patients. Provision of sedation or supplemental analgesia requires the presence of an anaesthesiologist, a standard acknowledged by regional anaesthesia societies.1 The immediate absence of the anaesthesiologist in this situation may lead to both an interruption in surgery but also degrades the patient’s experience as well as trust resulting in increased levels of anxiety and potentially harm to the patient. Patient safety A core role of the anaesthesiologist is to maintain patient safety. The ability to vigilantly monitor a patient is by no means a unique skill held by our profession, however the role of the anaesthesiologist extends far beyond the basic interpretation and documentation of vital signs and should not be underestimated. Detection and correction of physiological deviations as well as rapid and effective crisis management should catastrophe occur are competencies that require comprehensive theoretical and practical knowledge, extensive experience and refined non-technical skills. These competencies are practiced daily by anaesthesiologists and indeed take years to perfect.9 Although surgery under peripheral nerve block may avoid some of the hazards of general anaesthesia, emergencies can and do occur. Management often requires urgent advanced skills such as airway management, IV access and selection and administration of emergency medicines. While a minority of our allied health professionals may be able to perform these tasks, ultimately definitive management will require the presence of a trained anaesthesiologist. Anaesthetic Workload An often-cited benefit of relaxing the requirement for an anaesthesiologist to be present with the patient under regional anaesthesia is an improvement in efficiency, in that a single anaesthesiologist may provide regional anaesthesia for multiple patients. What is often overlooked in this context is the significant workload required of the anaesthesiologist beyond the insertion of the block, much of which cannot be delegated. Documentation of the block, teaching and, perhaps most importantly, patient counselling regarding post-block care all often take place during the relative ‘down-time’ of a straightforward awake case under peripheral nerve blockade. Management of block failure, which may occur in up to 10% of cases,10 is another responsibility that cannot be delegated to a non-anaesthesiologist. Any gains in efficiency made by a single practitioner providing anaesthesia but not theatre supervision to multiple patients may be offset by the lack of a competent individual available to manage a failed block. Finally, efficiency must not come at the cost of safety. Regional Anaesthesia UK (RA-UK) propose that a patient may be supervised in theatre by a non-anaesthesiologist provided that the anaesthesiologist is not only present for the 1st 15 minutes after block insertion but is also available to attend to the patient in theatre within 2 minutes should they be required.1 While advocating for efficiency, a potentially dangerous dilution of anaesthetic attention is also inadvertently encouraged. Adhering to these suggestions could feasibly lead to an anaesthesiologist being needed urgently in more than one place at a time. References Regional Anaesthesia UK. RA-UK guidelines for supervision of patients during peripheral regional anaesthesia; 2015. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring; 2020. Australia and New Zealand College of Anaesthetists and Faculty of Pain Medicine. PG18(A) Guideline on monitoring during anaesthesia. 2017. Klein AA, Meek T, Allcock E, Cook TM, Mincher N, Morris C, Nimmo AF, Pandit JJ, Pawa A, Rodney G, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2021: Guideline from the Association of Anaesthetists. Anaesthesia 2021. DOI: 10.1111/anae.15501. Mavridou P, Dimitriou V, Manataki A, Arnaoutoglou E, Papadopoulos G. Patient’s anxiety and fear of anesthesia: effect of gender, age, education, and previous experience of anesthesia. A survey of 400 patients. J Anesth 2013;27(1):104-108. DOI: 10.1007/s00540-012-1460-0. Walker EMK, Bell M, Cook TM, Grocott MPW, Moonesinghe SR, Organisation CS.-.; Groups, N. S. Patient reported outcome of adult perioperative anaesthesia in the United Kingdom: a cross-sectional observational study. Br J Anaesth 2016;117(6):758-766. DOI: 10.1093/bja/aew381. Lumb AB, Latchford GJ, Bekker HL, Hetmanski AR, Thomas CR, Schofield CE. Investigating the causes of patient anxiety at induction of anaesthesia: A mixed methods study. J Perioper Pract 2021;31(7-8):246-254. DOI: 10.1177/1750458920936933. Stamenkovic DM, Rancic NK, Latas MB, Neskovic V, Rondovic GM, Wu JD, Cattano D. Preoperative anxiety and implications on postoperative recovery: what can we do to change our history. Minerva Anestesiol 2018;84(11):1307-1317. DOI: 10.23736/S0375-9393.18.12520-X. Larsson J. Monitoring the anaesthetist in the operating theatre – professional competence and patient safety. Anaesthesia 2017;72(Suppl 1):76-83. DOI: 10.1111/anae.13743. Barrington MJ, Watts SA, Gledhill SR, Thomas RD, Said SA, Snyder GL, Tay VS, Jamrozik K. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other complications. Reg Anesth Pain Med 2009;34(6):534-541. DOI: 10.1097/aap.0b013e3181ae72e8.