Use of this content is subject to the Terms and Conditions of the MD Consult web site.
Brown: Atlas of Regional Anesthesia, 3rd ed., Copyright © 2006 Saunders, An Imprint of Elsevier
< Previous Next >


The necessary, but somewhat artificial, separation of anesthetic care into regional or general anesthetic techniques often ends with the concept that these two techniques should not or cannot be mixed. Nothing could be further from the truth. To provide comprehensive regional anesthesia care, it is absolutely essential that the anesthesiologist be skilled in all aspects of anesthesia. This concept is not original: John Lundy promoted this idea in the 1920s when he outlined his concept of “balanced anesthesia.” Even before Lundy promoted this, the familiar term, George Crile had written extensively on the concept of anociassociation, which was in reality the forerunner to balanced anesthesia.

It is often tempting, and quite human, to trace the evolution of a discipline back through the discipline’s developmental family tree. When such an investigation is carried out for regional anesthesia, Louis Gaston Labat, M.D. often receives credit for being central in its development. Labat’s interest and expertise in regional anesthesia had been nurtured by Dr. Victor Pauchet of Paris, France, to whom Dr. Labat was an assistant. The real trunk of the developmental tree of regional anesthesia consists of the physicians willing to incorporate regional techniques into their early surgical practices. In Labat’s original 1922 text Regional Anesthesia: Its Technique and Clinical Application, Dr. William Mayo in the foreword stated:

The young surgeon should perfect himself in the use of regional anesthesia, which increases in value with the increase in the skill with which it is administered. The well equipped surgeon must be prepared to use the proper anesthesia, or the proper combination of anesthesias, in the individual case. I do not look forward to the day when regional anesthesia will wholly displace general anesthesia; but undoubtedly it will reach and hold a very high position in surgical practice.

Perhaps if the current generation of surgeons and anesthesiologists had kept Mayo’s concept in mind, our patients would be the beneficiaries.

It appears that these early surgeons were better able to incorporate regional techniques into their practices because they did not see the regional block as the “end all.” Rather, they saw it as part of a comprehensive package that had benefit for their patients. Surgeons and anesthesiologists of that era were able to avoid the flawed logic that often seems to pervade application of regional anesthesia today. These individuals did not hesitate to supplement their blocks with sedatives or light general anesthetics; they did not expect each and every block to be “100%.” The concept that a block has failed unless it provides complete anesthesia without supplementation seems to have occurred when anesthesiology developed as an independent specialty. To be successful in carrying out regional anesthesia, we must be willing to return to our roots and embrace the concepts of these early workers who did not hesitate to supplement their regional blocks. Ironically, today some consider a regional block a failure if the initial dose does not produce complete anesthesia; yet these same individuals complement our “general anesthetists” who utilize the concept of anesthetic titration as a goal. Somehow, we need to meld these two views into one that allows comprehensive, titrated care to be provided for all our patients.

As Dr. Mayo emphasized in Labat’s text, it is doubtful that regional anesthesia will “ever wholly displace general anesthesia.” Likewise, it is equally clear that general anesthesia will probably never be able to replace the appropriate use of regional anesthesia. One of the principal rationales for avoiding the use of regional anesthesia through the years has been that it was “expensive” in terms of operating room and physician time. As is often the case, when examined in detail some accepted truisms need rethinking. Thus, it is surprising that much of the renewed interest in regional anesthesia results from focusing on health care costs and the need to decrease the length and cost of hospitalization.

If regional anesthesia is to be incorporated successfully into a practice, there must be time for anesthesiologist and patient to discuss the upcoming operation and anesthetic prescription. Likewise, if regional anesthesia is to be effectively used, some area of an operating suite must be utilized to place the blocks prior to moving patients to the main operating room. Immediately at hand in this area, one needs both anesthetic and resuscitative equipment (regional trays and so on), as well as a variety of local anesthetic drugs that can be used to walk along the time line of anesthetic duration. Even after successful completion of the technical aspect of regional anesthesia, an anesthesiologist’s work is really just beginning. To emphasize this point, it is as important intraoperatively to use appropriate sedation as it was preoperatively while the block was being administered.

< Previous Next >

About MD Consult Contact Us Terms and Conditions Privacy Policy Registered User Agreement
Copyright © 2007 Elsevier Inc. All rights reserved. 
Bookmark URL: /das/book/0/view/1353/5.html/top