LEUVEN, Belgium—There are excellent arguments in favor of standardizing the approaches used in regional anesthesia, and yet restricting clinical choices may be problematic in some settings. Both sides of the argument were explored in a pro–con debate held at NYSORA’s 2024 Anesthesia Summit.
Standardization Is the Future
Arguing forcefully in favor of standardization was Admir Hadzic, MD, PhD, the founder of NYSORA, who is a member of the Department of Anesthesiology at Ziekenhuis Oost-Limburg (ZOL), in Genk, Belgium.
“What is meant by standardization? I think it is simple,” Hadzic said. “You need to establish uniform protocols and guidelines for everybody on your team. Can you imagine if you were running an anesthesia service and you have a staff of 50 people, 30 of whom know how to intubate and 20 who don’t? It’s the same thing with regional anesthesia. You need to have protocols and guidelines, and you need to ensure adherence to best practices throughout.”
Referring to NYSORA, Hadzic said, “one of our missions is to not only teach regional anesthesia but also to standardize, because without standardization I don’t believe that regional anesthesia as a discipline actually has a future.” Strong words, particularly since the regional practice at ZOL is so robust.
“It’s a very, very busy practice, and during any given year, our fellows and residents will administer about 10,000 peripheral nerve blocks,” Hadzic said. “So, the importance of regional anesthesia is not questionable.”
But, according to Hadzic, variability in techniques may lead to variability in outcomes.
“In private practice, we eat what we kill,” he said. “Meaning the more patients there are, the more anesthetics we administer and the more money we make.” Variability in technique is the enemy of efficiency, he noted.
Furthermore, outcomes may suffer. “If everyone in your practice does a different procedure for the same surgical indication, then you will have reproducibility issues in which there will be differences in outcomes from patient to patient and from clinician to clinician,” Hadzic said, “and then it will be a lot more difficult for your nurses and your surgeons to manage each patient postoperatively.”
Hadzic argued that “standardized protocols lead to predictable and reproducible outcomes because every patient will get the same anesthetic, with the same technique, with the same dosing and the same medication, so outcomes should be the same.”
Nurses, he argued, dislike it when the expected approach is changed. With standardization, they prepare the exact setup needed, with the exact equipment needed and with the correct anesthetics.
“The only difference between team members in preparations will be the size of their gloves—all else is standardized.”
Yes, but Never Forget to Think
For Steve Coppens, MD, an anesthesiologist at University Hospitals of Leuven, where he is the clinical director of locoregional anesthesia and head of clinic, the use of standardized protocols makes obvious sense, for all the reasons noted by Hadzic.
Coppens’ work at University Hospitals includes a considerable regional anesthesia practice, as well as oversight of an approved fellowship from the European Society of Regional Anaesthesia and Pain Therapy. His extensive involvement in the specialty has led him to conclude, “There are advantages to standardization, but also disadvantages.”
The disadvantages lie in exceptional cases that may challenge protocolized assumptions. For instance, “if I have a patient with a BMI of 40 kg/m2,” Coppens said, “I would not give the same amount of anesthetic as a 90-year-old lady who only weighs 40 kg and has albuminemia. So, the most important point about standardizing is to please, please use your mind.”
Another problem with standardization is that it fails to distinguish variabilities among providers. He noted that an editorial by Turbitt et al in Anaesthesia (2020;75[3]:293-297), titled “Future Directions in Regional Anaesthesia: Not Just for the Cognoscenti,” envisioned a day when technical prowess will be evenly dispersed. “Will there be 30 of my colleagues who are as good as I am doing an axillary block?” he asked. “No, it’s just not going to happen. You need people who are better at it. You need a team, and trying to democratize regional anesthesia will just lead to failure.”
For Coppens, “standardization leads to rigidity and rigidity causes things to break.” He discussed a study that explored the cutaneous innervation of the hands of 12 volunteers, with markedly differing results among the participants. “Do you really think your standardized wrist block will always get sufficient results?” he asked, pointing to the divergent innervation. “Think again! Keep your mind open and be careful of over-standardization.”
In the end, both Hadzic and Coppens agreed on the utility of standardized protocols, with the former emphasizing the benefits and the latter emphasizing the importance of maintaining vigilance. Hadzic, of course, also stresses vigilance, and Coppens agrees that standardization has benefits, so their varying approaches ultimately lead to overall agreement. Standardize, but keep thinking.
By James Prudden
Coppens reported receiving compensation from B. Braun Medical, MSD, Pajunk, Sonosite and Wisonic, which he has fully invested in Funding For Fellows (F3), which gives travel grants to locoregional anesthesia fellows from UZ Leuven. Hadzic has consulted, advised and/or performed sponsored research for Baxter, B. Braun Medical, Cadence, Codman & Shurtleff (Johnson and Johnson), Fujifilm Sonosite, GE, Heron Therapeutics, InSitu Biologics, Konica Minolta, Pacira and Phillips. He receives royalty income from B. Braun Medical and McGraw Hill Publishing.