To block or not to block, that is the question…

Lewis SC, Warlow CP, Bodenham AR et al. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet 2008; 372: 2132

RHH Journal Club. May 24th, 2012. Dr Jamie Douglass

No free full-text available

Prediction and prevention of perioperative strokes [carotid surgery] might be easier under local anaesthesia than under general anaesthesia

Study design:

  • Therapeutic assessment.
  • Multicentre randomised controlled trial.
  • Two parallel arms.

Methodology

Population:

  • 3526 patients with symptomatic or asymptomatic internal carotid stenosis for whom open surgery was advised, enrolled between June 1999 and October 2007.
  • Exclusions: simultaneous bilateral surgery; combination with another operative procedure such as CABG; or if patients had previously taken part in the trial.

Intervention:

  • Local anaesthesia (superficial and deep cervical plexus blocks) or general anaesthesia for carotid artery surgery.
  • Shunts were used in patients undergoing surgery with local anaesthesia when awake testing indicated a need.

Control:

  • Random assignment to local or general anaesthesia treatment groups.
  • Stratified by centre and used balanced blocks of variable size.
  • In parallel

Outcomes:

  • Primary – The proportion of patients alive, stroke-free and without myocardial infarction at 30 days after surgery.
  • Secondary –  Survival free of stroke,MI, or death up to 1 year later; length of stay in recovery, HDU, ITU and overall stay in hospital

Validity:

  • Centrally randomised treatment allocation, stratified by centre.
  • Intention to treat analysis.
  • Unable to blind surgical team or patient! Attempted to blind independent assessor of primary outcomes at one month after surgery, but notes available to them.

Results:

  • Stroke, MI or death occurred  in 84 (4·8%) patients assigned to surgery under general anaesthesia and 80 (4·5%) of those assigned to surgery under local anaesthesia.
  • Three events per 1000 patients treated were prevented with local anaesthesia (95% CI  -11 to 17; risk ratio [RR] 0·94 [95% CI 0·70 to 1·27]).

Conclusions:

  • The trial did not shown a statistically significant difference in outcomes.
  • The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis.
  • Ideally, surgical and anaesthetic teams should be competent in both techniques because a patient may prefer, or there may be a medical reason, to choose one over the other.
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