Here are my slides from my pro-con debate with Prof Neuman at ASRAWorld18 in NYC. - It was a lighthearted debate in the setting of a court case with General Anaesthesia being "put on trial" - I was the defense attorney

1. The people vs. general anesthesia
The Defense
(“Defence” for the British/Canadians/Australians!)
19th April 2018
Dr Amit Pawa MBBS(Hons) FRCA
@amit_pawa

2. Faculty Disclosure
Honoraria/Expenses Honoraria from GE Healthcare for teaching
Consulting/Advisory Board B Braun Medical Ltd
Speakers Bureau
Funded Research (Individual)
Funded Research (Institution)
Royalties/Patent
Stock Options
Ownership/Equity Position
Employee
Other
Dr Amit Pawa
Yes, as follows:
Off-Label Product Use
Will you be presenting or referencing off-label or investigational use of a therapeutic product?
No

3. The Plea
Increasing the global burden of postoperative morbidity
among older adults undergoing surgery for hip fracture repair
Increasing the global burden of postoperative mortality
among older adults undergoing surgery for hip fracture repair
NOT GUILTY
NOT GUILTY

4. I will argue that General Anesthesia
has a useful role in management of
Adult Hip Fracture

5. In order to be found Guilty…
The prosecutor must prove
General Anesthesia’s guilt
Beyond a Reasonable Doubt…
(To a Group of Regional Anesthesia Enthusiasts!)
(At the World Congress in Regional Anesthesia!)

6. High Risk Population ANYWAY
* 8-10% die within 30 days of fracture
* 15-30-% die within 1 year of surgery
Varied Practice Worldwide
High vs Low Dose Spinal
Intrathecal opiates vs none
Sedation vs No Sedation
GA with/without Block
* Griffiths R, Alper J, Beckingsale A, et al. AAGBI Guidelines: management of proximal femoral fractures 2011.
Anaesthesia 2012; 67: 85–98.
Lets Be Real

7. General Anesthesia :
Absolute phenomenon & It WORKS (100%)
Can be Supplemented by Nerve Block
Regional Anesthesia (RA):
Can FAIL
Variable Feast (Spinal/Epidural/Lumbar Plexus..)
Has Contraindications (Clopidgrel(Plavix) & newer DOACs)
RA is not always sited by experts LIKE YOU
Lets Be Even More Real

8. On-Call, 2 weeks ago, True Story …
WOULD YOU SITE A SPINAL?
“Dr Pawa, I have a 94 yr old #NOF with:
Atrial Fibrillation,
Aortic Stenosis,
Dementia,
Pressure sores;
…Oh, and she is on Rivaroxaban”

9. Mortality
30-day
Surgery
2 hrs Anesthesia
OrthoGeriatric Care
Rehab ServicesNutrition
Physical TherapyComorbidity
Do WE really impact outcome over 2 hrs?

10. Evidence…

11. 83 Studies – (64 RCTS)
Nerve Blocks more effective than “standard care”
Spinal Anesthesia DID NOT DIFFER from GA in rates of
Mortality (30 day)
Delirium
MI, Renal Failure, Stroke
Comparative Effectiveness of Pain Management Interventions for Hip
Fracture: A Systematic Review
Ahmed M. Abou-Setta, MD, PhD; Lauren A. Beaupre, PT, PhD; Saifee Rashiq, MB, MSc; Donna M. Dryden, PhD; Michele P. Hamm, MSc;
Cheryl A. Sadowski, BSc(Pharm), PharmD; Matthew R.G. Menon, MD, MHSc; Sumit R. Majumdar, MD, MPH; Donna M. Wilson, RN, PhD;
Mohammad Karkhaneh, MD; Shima S. Mousavi, MD; Kai Wong, MSc; Lisa Tjosvold, MLIS; and C. Allyson Jones, PT, PhD
Background: Pain management is integral to the management of
hip fracture.
Purpose: To review the benefits and harms of pharmacologic and
nonpharmacologic interventions for managing pain after hip
fracture.
Data Sources: 25 electronic databases (January 1990 to December
2010), gray literature, trial registries, and reference lists, with no
language restrictions.
Study Selection: Multiple reviewers independently and in duplicate
screened 9357 citations to identify randomized, controlled trials
(RCTs); nonrandomized, controlled trials (non-RCTs); and cohort
studies of pain management techniques in older adults after acute
hip fracture.
Data Extraction: Independent, duplicate data extraction and quality
assessment were conducted, with discrepancies resolved by consen-
(n ϭ 2), rehabilitation (n ϭ 1), and complementary and alternative
medicine (n ϭ 2). Overall, moderate evidence suggests that nerve
blockades are effective for relieving acute pain and reducing delir-
ium. Low-level evidence suggests that preoperative traction does
not reduce acute pain. Evidence was insufficient on the benefits
and harms of most interventions, including spinal anesthesia, sys-
temic analgesia, multimodal pain management, acupressure, relax-
ation therapy, transcutaneous electrical neurostimulation, and phys-
ical therapy regimens, in managing acute pain.
Limitations: No studies evaluated outcomes of chronic pain or
exclusively examined participants from nursing homes or with cog-
nitive impairment. Systemic analgesics (narcotics, nonsteroidal anti-
inflammatory drugs) were understudied during the search period.
Conclusion: Nerve blockade seems to be effective in reducing
acute pain after hip fracture. Sparse data preclude firm conclusions
about the relative benefits or harms of many other pain manage-
ment interventions for patients with hip fracture.
Annals of Internal MedicineReview 2011

12. No Difference in Mortality
Regional Anesthesia Vs GA
2014
2014
73,000 patients
56,000 patients

13. 65,535 Patient dataset
NO SIGNIFICANT DIFFERENCE between GA & Spinal for:
5 day mortality OR 30 day mortality
Original Article
Outcome by mode of anaesthesia for hip fracture surgery. An
observational audit of 65 535 patients in a national dataset
S. M. White,1
I. K. Moppett2
and R. Griffiths3
1 Consultant Anaesthetist, Brighton and Sussex University Hospitals NHS Trust, Brighton, East Sussex, UK
2 Associate Professor and Honorary Consultant Anaesthetist, Anaesthesia and Critical Care Research Group, Division
of Clinical Neuroscience, University of Nottingham, Queen’s Medical Centre Campus, Nottingham University Hospitals
NHS Trust, Nottingham, UK
3 Consultant Anaesthetist, Peterborough and Stamford Hospitals NHS Trust, Peterborough, UK
Summary
Large observational studies of accurate data can provide similar results to more arduous and expensive randomised
controlled trials. In 2012, the National Hip Fracture Database extended its dataset to include ‘type of anaesthesia’
data fields. We analysed 65 535 patient record sets to determine differences in outcome. Type of anaesthesia was
recorded in 59 191 (90%) patients. Omitting patients who received both general and spinal anaesthesia or in whom
an uncertain type of anaesthesia was recorded, there was no significant difference in either cumulative five-day (2.8%
vs 2.8%, p = 0.991) or 30-day (7.0% vs 7.5%, p = 0.053) mortality between 30 130 patients receiving general anaes-
thesia and 22 999 patients receiving spinal anaesthesia, even when 30-day mortality was adjusted for age and ASA
physical status (p = 0.226). Mortality within 24 hours after surgery was significantly higher among patients receiving
cemented compared with uncemented hemiarthroplasty (1.6% vs 1.2%, p = 0.030), suggesting excess early mortality
related to bone cement implantation syndrome. If these data are accurate, then either there is no difference in
30-day mortality between general and spinal anaesthesia after hip fracture surgery per se, and therefore future
research should focus on how to make both types of anaesthesia safer, or there is a difference, but mortality is not
the correct outcome to measure after anaesthesia, and therefore future research should focus on differences between
general and spinal anaesthesia. These could include more anaesthesia-sensitive outcomes, such as hypotension, pain,
postoperative confusion, respiratory infection and mobilisation.
.................................................................................................................................................................
Correspondence to: S. M. White
Email: stuart.white@bsuh.nhs.uk
Accepted: 17 November 2013
Anaesthesia 2014, 69, 224–230 doi:10.1111/anae.12542
Mode of Anesthesia 30 day Mortality
All Spinal (Spinal +/- nerve block/epidural) 7.5%
All GA (GA +/- nerve block/epidural) 7.0%
GA plus Spinal 6.7%
2014

14. Cochrane Database of Systematic Reviews
Anaesthesia for hip fracture surgery in adults (Review)
Guay J, Parker MJ, Gajendragadkar PR, Kopp S
Cochrane Database of Systematic Reviews
Anaesthesia for hip fracture surgery in adults (Review)
Guay J, Parker MJ, Gajendragadkar PR, Kopp S
Guay J, Parker MJ, Gajendragadkar PR, Kopp S.
Anaesthesia for hip fracture surgery in adults.
Cochrane Database of Systematic Reviews 2016, Issue 2. Art. No.: CD000521.
DOI: 10.1002/14651858.CD000521.pub3.
www.cochranelibrary.com
Anaesthesia for hip fracture surgery in adults (Review)
RA vs GA for Hip Fracture repair
Spinal Anesthesia DID NOT DIFFER from GA in rates of
Mortality (30 day) – 2152 patients
Pneumonia – 761 patients
MI (559), Stroke (729),Delirium (624)
”LOW QUALITY EVIDENCE” – but certainly not evidence of guilt
2016

15. Original Article CPD available at http://www.learnataagbi.org
Secondary analysis of outcomes after 11,085 hip fracture
operations from the prospective UK Anaesthesia Sprint Audit of
Practice (ASAP-2)
S. M. White,1
I. K. Moppett,2
R. Griffiths,3
A. Johansen,4
R. Wakeman,4
C. Boulton,4
F. Plant,5
A. Williams,6
K. Pappenheim,7
A. Majeed,8
C. T. Currie9
and M. P. W. Grocott10
1 Consultant Anaesthetist, Brighton and Sussex University Hospitals NHS Trust, Brighton, East Sussex, UK
2 Associate Professor and Honorary Consultant, Anaesthesia and Critical Care Section, Division of Clinical
Neuroscience, University of Nottingham, Queen’s Medical Centre Campus, Nottingham University Hospitals NHS
Trust, Nottingham, UK
3 Consultant Anaesthetist, Peterborough and Stamford Hospitals NHS Trust, Peterborough, UK
4 Consultant Orthogeriatrician, National Hip Fracture Database, Falls and Fragility Fracture Audit Programme,
Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK
5 Ward Sister, The Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
6 National Hip Fracture Database Project Co-ordinator, Gloucestershire Royal Hospital, Gloucester, Gloucestershire, UK
7 Executive Director, Association of Anaesthetists of Great Britain and Ireland, London, UK
8 Consultant Anaesthetist, King Fahad Medical City, Riyadh, Saudi Arabia
9 Lead Geriatrician 2007-11, National Hip Fracture Database, London, UK
10 Professor, Anaesthesia and Critical Care Medicine, University of Southampton and Southampton NIHR Respiratory
Biomedical Research Unit, Southampton, UK
Summary
We re-analysed prospective data collected by anaesthetists in the Anaesthesia Sprint Audit of Practice (ASAP-1) to
describe associations with linked outcome data. Mortality was 165/11,085 (1.5%) 5 days and 563/11,085 (5.1%)
30 days after surgery and was not associated with anaesthetic technique (general vs. spinal, with or without periph-
eral nerve blockade). The risk of death increased as blood pressure fell: the odds ratio (95% CI) for mortality within
five days after surgery was 0.983 (0.973–0.994) for each 5 mmHg intra-operative increment in systolic blood pres-
sure, p = 0.0016, and 0.980 (0.967–0.993) for each mmHg increment in mean pressure, p = 0.0039. The equivalent
odds ratios (95% CI) for 30-day mortality were 0.968 (0.951–0.985), p = 0.0003 and 0.976 (0.964–0.988), p = 0.0001,
respectively. The lowest systolic blood pressure after intrathecal local anaesthetic relative to before induction was
2
Anaesthesia 2016, 71, 506–514 doi:10.1111/anae.13415
Prospective data on 11,085 pts
NO SIGNIFICANT DIFFERENCE between GA & Spinal for:
5 day mortality OR 30 day mortality
BUT…
2016
Blood Pressure (mmHg)
Mortality %
70 130
8
2
Systolic BP <85mmHg Higher Systolic BP
5.9% 30-Day Mortality 4.6% 30-Day Mortality

16. Perioperative outcomes in the context of mode of
anaesthesia for patients undergoing hip fracture
surgery: systematic review and meta-analysis
C.M. O’Donnell1,
*, L. McLoughlin1
, C.C. Patterson2
, M. Clarke2
,
K.C. McCourt1
, M.E. McBrien1
, D.F. McAuley1,3
and M.O. Shields1
1
Royal Victoria Hospital, Belfast Health and Social Care Trust, Grosvenor Road, Belfast BT12 6BA,
UK, 2
Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Institute of Clinical
Sciences, Block B, Queen’s University of Belfast, Belfast BT12 6BA, UK and 3
Centre for Experimental
Medicine, School of Medicine, Dentistry and Biomedical Sciences, WellcomeeWolfson Institute, Queen’s
University of Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
*Corresponding author. E-mail: codonnell11@qub.ac.uk.
Abstract
Background: Previous meta-analyses on the anaesthetic management of patients undergoing surgery for hip fracture
have focused on randomized trials. Furthermore, heterogeneity in outcome reporting across the studies has made it
difficult to inform best practice guidelines for patient care.
Methods: This systematic review examined how perioperative outcomes were reported and defined in the context of
comparing modes of anaesthesia for hip fracture surgery. Outcomes were included from randomised and non-rando-
mised studies published between January 2000 and July 2017. Meta-analyses were performed for regional versus general
anaesthesia, with sensitivity analyses performed for spinal versus general anaesthesia.
Results: By including data from 15 large observational studies in this meta-analysis, we have increased the number of
patients for whom outcomes were assessed from approximately 3000 to 202 000. There was no significant difference in
30-day mortality [Odds ratio (OR) 1.15; 95% confidence interval (CI) 1.01, 1.32; I2
87%; n¼200 464], prevalence of pneumonia
(OR 1.10; 95% CI 0.93, 1.30; I2
43%; n¼65 011), acute myocardial infarction (OR 0.96; 95% CI 0.88, 1.05; I2
0%, n¼64 904),
delirium (OR 1.07; 95% CI 0.72, 1.58; I2
93%, n¼19 923) or renal failure (OR 0.94; 95% CI 0.54, 1.64; I2
0%, n¼27 873) for
regional compared to general anaesthesia.
There was a small statistically significant difference for length of stay (standardized mean difference e0.03; 95% CI e0.05,
e0.02; I2
0%; n¼78 711) favouring regional anaesthesia, which is unlikely to be clinically significant. Sensitivity analyses
for the same outcomes examining spinal only vs general anaesthesia showed minor statistical significance for length of
stay favouring spinal. We also present data highlighting the scale of the inconsistencies in reported outcomes across 32
studies, making evaluation in a standardized manner very difficult. As an example, mortality was reported in nine
Perioper
anaesthe
surgery:
C.M. O’Don
K.C. McCou
1
Royal Victoria H
UK, 2
Centre for P
mes in the context of mode of
ients undergoing hip fracture
c review and meta-analysis
ughlin1
, C.C. Patterson2
, M. Clarke2
,
1 1,3 1
British Journal of Anaesthesia, 120(1): 37e50 (2018)
doi: 10.1016/j.bja.2017.09.002
Advance Access Publication Date: 24 November 2017
Review Article
17 years data
202,000 patients – RCT & Obs Studies
RA vs GA
NO SIGNIFICANT DIFFERENCE IN:
30 Day Mortality
Prevalence of Pneumonia
Acute Myocardial Infarction
Delirium
Renal Failure
2018

17. Guidelines
International Fragility Fracture Network Delphi consensus
statement on the principles of anaesthesia for patients with hip
fracture
S. M. White,1
F. Altermatt,2
J. Barry,3
B. Ben-David,4
M. Coburn,5
F. Coluzzi,6
M. Degoli,7
D. Dillane,8
N. B. Foss,9
A. Gelmanas,10
R. Griffiths,11
G. Karpetas,12
J.-H. Kim,13
M. Kluger,14
P.-W. Lau,15
I. Matot,16
M. McBrien,17
S. McManus,18
L. F. Montoya-Pelaez,19
I. K. Moppett,20
M. Parker,21
O. Porrill,22
R. D. Sanders,23
C. Shelton,24
F. Sieber,25
A. Trikha26
and X. Xuebing27
1 Consultant Anaesthetist, Brighton and Sussex University Hospitals NHS Trust, Brighton, East Sussex, UK
2 Associate Professor, Division de Anestesiologıa, Escuela de Medicina, Pontificia Universidad Catolica de Chile,
Santiago, Chile
3 Consultant Anaesthetist, Cairns Hospital, Queensland, Australia
4 Professor of Anesthesiology, University of Pittsburgh Medical Centre, Pittsburgh, PA, USA
5 Consultant Anaesthetist, Medical Faculty, RWTH Aachen University, Aachen, Germany
6 Professor of Anaesthesia, Department Medical and surgical sciences and biotechnologies, Sapienza University of
Rome, Polo Pontino, Latina, Italy
7 Consultant Anaesthetist, Ospedale Civile di Baggiovara, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
8 Associate Professor, Anesthesiology and Pain Medicine, University of Alberta, Canada
9 Associate Professor, Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital,
Hvidovre, Denmark
10 Consultant Anaesthetist, Hospital of Lithuanian University of Health Sciences Kauno klinikos, Lithuania
11 Professor of Anaesthesia, Peterborough and Stamford Hospitals NHS Trust, Peterborough, UK
12 Consultant Anaesthetist, General University Hospital of Patras, Rio, Greece
13 Professor of Anaesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, South Korea
Anaesthesia 2018 doi:10.1111/anae.14225
EITHER GA or RA should be offered
Surgery within 48hrs by Appropriately Experienced Anesthesiologist
Appropriate Doses of Anesthesia/Analgesia
Maintain BP Core temperature
Monitor Depth of Anesthesia
Hot off the Press!
28 World Experts in Hip Fracture Anesthesia
2018

18. “It Aint What You Do, It’s The Way You Do It”
NO reliable evidence at present to support Charges
Prosecution CANNOT Prove Guilt Beyond reasonable doubt
Perform Excellent Anesthesia, GA or Regional
(It Aint What You Do)
Perform it Well - THIS IS KEY
(It’s The Way You Do It”)
Provide Infrastructure for Recovery Rehabilitation

19. We Are Also Humans, with Feelings…
We Are Scientists Clinicians
What does the Patient Want?
“Hip Fracture care should be based on the
needs of the PATIENT, not the desires of the
anaesthetist”
Prof Iain Moppett

20. Close Your Eyes…
• Imagine being in dreadful pain, searing shooting in your hip and
groin and radiating down your thigh
• Imagine being scared, distressed, confused helpless
• Imagine hearing voices around you, talking as if you are not there
• Imagine feeling you are outside your body looking in
• Imagine hearing drills and saws, and people pulling and pushing on
your leg, stretching and bending it into places its not supposed to
go.
• Imagine how you might feel having surgery like that…

21. Now Open Your Eyes…
• Imagine you have woken up after your General Anesthetic
• You feel fine, you are slightly drowsy, but comfortable
• Your anesthesiologist has maintained your blood pressure,
given you just enough anesthesia, and woken you up feeling
orientated and pain free
What does the Patient Want?
What do YOU Want?

22. Ideal Pathway…
• Diagnosis of Hip Fracture
• Nerve Catheter
• Titrated multimodal analgesia
• Pre-operative: Assessment Optimization Nutrition
• Choice of GA or RA by experienced practitioner within 48hr
• Blood Pressure maintained
• Depth of Anesthesia monitored
• OrthoGeriatric input Early Mobilization
• Discharge

23. Use Your Vote Wisely
On the Basis of the current Evidence your Honor…
You can only find General Anesthesia…
NOT GUILTY