Is there a recommendation for safety in the practice of regional anesthesia?

LETTER TO THE EDITOR

Is there a recommendation for safety in the practice of regional anesthesia?

Fabiano Timbó Barbosa

MD, Universidade Federal de Alagoas

Dear Editor,

It was with great interest that I read the article published in the RBA, guiding professionals on safety in the administration of regional blocks ¹. I congratulate the authors for their effort and seriousness with which they handled this subject. I would like to make a few remarks on three topics:

1. References

Anesthesia is a medical procedure that has changed over the years due to technological and pharmacological advances, so it would be appropriate to think that the techniques used today are not the same as those used in the past. When reading the references, it became clear that the authors used publications assessing patients enrolled in studies of anesthesia in the past decades. The text does not clarify how the authors have acted before such limitation or if it was considered at some point during the analysis of the articles included in the recommendations. Would it be possible to clarify this?

The strategy used to identify the included articles did not make clear what moment or step allowed the use of book chapters. A chapter of a book was used, but observing its content, it seems that it addresses the American pharmacopoeia and not specifically the practice of world anesthesia ².

2. Theoretical starting point

The authors' concern was to focus on infectious complications related to regional block; however, it is important to emphasize that such complications are rare - "There is no clear evidence in literature regarding the frequency of such complications (D)" and "Also rare is drug administration errors in regional block" (?). Therefore, the creation of recommendations without previous knowledge of the actual or estimated frequency of events may be seen with reservations. Would it be possible to the authors to do a research in Brazil together with the Brazilian Society of Anesthesiology to identify the current frequency of such events and thus make it feasible to consult the recommendations?

The authors use epidemiological series to justify that even in the absence of published information, the frequency of infectious complications and accidents are on the rise. Nevertheless, the studies used as reference were conducted in the 80s and 90s, remaining doubtful the current state of events ^3-6.

3. Grading of recommendation and strength of evidence

There are recommendations based only on publications with evidence level D, leading the authors to assume a position less affirmative in the text. Thus, some recommendations were a little dubious requiring a better explanation of the topic by the authors. For example: "(...) except in the most extraordinary circumstances, neuraxial blockade should not be performed in patients with untreated systemic infection." "Visiting an infectologist is recommended to facilitate early and effective antibiotic therapy." "ANVISA (National Health Surveillance Agency) does not recommend reprocessing of materials for use in regional anesthesia (...)". The concept of "extraordinary circumstance", if visiting an infectologist may influence decision making on choosing the anesthetic technique, and if there are hospitals that still use reprocessed material in Brazil were not clear in the text.

The authors did not report the use of systematic reviews and meta-analyses, which is necessary to understand if there was any exclusion criteria to set aside this type of research, or if there are no such researches analyzing this topic.

In short, there are recommendations and they should be used in the presence of patients in clinical practice. However, some points should be viewed with caution due to the strength of evidences that generated certain recommendations, particularly those based solely on evidence level D. We need to know the frequency of infectious anesthetic complications in Brazil.

REFERENCES

• 1. Fernandes CR, Fonseca NM, Rosa DM et al. - Recomendações da Sociedade Brasileira de Anestesiologia para segurança em anestesia regional. Rev Bras Anestesiol, 2011;61:668-694.
• 2. USP Chapter 797 with proposed revisions 2006 - Disponível em: [http://www.usp.org/pdf/EN/USPNF/PF797redline.pdf
• 3. Moen V, Dahlgren N, Irestedt L - Severe neurological complications after central neuraxial blockades in Sweden 1990-1999. Anesthesiology, 2004;101:950-959.
• 4. Horlocker TT, McGregor DG, Matsushige DK et al. - A retrospective review of 4,767 consecutive spinal anesthetics: central nervous system complications. Perioperative Outcomes Group. Anesth Analg, 1997;84(3):578-584.
• 5. Wang LP, Hauerberg J, Schmidt JF - Incidence of spinal epidural abscess after epidural analgesia: a national 1-year survey. Anesthesiology, 1999;91(6):1928-1936.
• 6. Aromaam U, Lahdensuu DA, Cozanitis S - Severe complications associated with epidural and spinal anaesthesias in Finland 1987-1993. A study based on patient insurance claims. Acta Anaesthesiol Scand, 1997;41:445-452.

Publication Dates

• Publication in this collection
  25 Sept 2012
• Date of issue
  Oct 2012