title: Awake, sedated or anaesthetised for regional anaesthesia block placements?: A retrospective registry analysis of acute complications and patient satisfaction in adults.
abstract: BACKGROUND
  Whether adults should be awake, sedated or anaesthetised during establishment of regional anaesthesia is still debated and there is little information on the relative safety of each. In paediatric practice, there is often little choice but to use sedation or anaesthesia as otherwise the procedures would be too distressing and patient movement would be hazardous.
  
  
  OBJECTIVE
  The objective of this study was to evaluate complications related to central and peripheral regional block and patient satisfaction in awake, sedated and anaesthetised adult patients.
  
  
  METHODS
  A retrospective registry analysis.
  
  
  METHODS
  The German Network of Regional Anaesthesia database was analysed between 2007 and 2012.
  
  
  METHODS
  We included data of 42 654 patients and defined three groups: group I awake (n = 25 004), group II sedated (n = 15 121) and group III anaesthetised (n = 2529) for block placement.
  
  
  METHODS
  Odds ratios [OR; 95% confidence interval (CI)] were calculated with logistic regression analysis and adjusted for relevant confounders to determine the risk of block-related complications in sedated or anaesthetised patients compared with awake patients.
  
  
  RESULTS
  Rates of local anaesthetic systemic toxicity were comparable between the groups [awake 0.02% (95% CI: 0.002 to 0.0375), sedated 0.02% (0.003 to 0.042) and anaesthetised 0% (0 to 0.12%)], as were the rates of pneumothorax [awake 0.035% (0 to 0.074), sedated 0% (0 to 0.002) and anaesthetised 0.2% (0 to 0.56)]. Considering peripheral nerve blocks, sedated patients had a decreased risk for multiple skin puncture [adjusted OR: 0.78 (95% CI: 0.71 to 0.85), premature termination [0.45 (0.22 to 0.91)], primary failure [0.58 (0.40 to 0.83)] and postoperative paraesthesia [0.35 (0.28 to 0.45)], but an increased risk for a bloody tap [1.82 (1.50 to 2.21)]. General anaesthesia increased the risk of a bloody tap [adjusted OR: 1.33 (95% CI: 1.01 to 1.78)] and multiple skin puncture [1.28 (1.12 to 1.46)], but decreased the risk for postoperative paraesthesia [0.16 (0.06 to 0.38)]. In neuraxial sites, sedation increased the risk for multiple skin puncture [adjusted OR: 1.18 (95% CI: 1.09 to 1.29)], whereas block placement under general anaesthesia decreased the risk for multiple skin puncture [0.53 (0.39 to 0.72)] and bloody tap but significantly increased the risk for postoperative paraesthesia related to a catheter [2.45 (1.19 to 5.02)]. Sedation was associated with a significant improvement in patient satisfaction.
  
  
  CONCLUSIONS
  Sedation may improve safety and success of peripheral nerve block placement. Block placement under general anaesthesia in adults should be reserved for experienced anaesthesiologists and special situations.
authors.affiliation: From the Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine (CK, KS, NA, AR, TV, H B), Department of Biostatistics and Medical Informatics, Institute for Epidemiology, University Medical Centre, University of Saarland, Homburg, Saar (SG), Department of Anaesthesiology, Intensive Care and Pain Medicine, Orthopaedic University Hospital, Frankfurt (PK), Department of Anaesthesiology and Intensive Care Therapy, Philipps University Marburg, Marburg (TS), Department of Anaesthesia, Intensive and Palliative Care Medicine, Academic Hospital Solingen, Solingen (TS), Department of Anaesthesiology, Intensive Care and Pain Medicine, Hannover (AG), Department of Anaesthesiology and Intensive Care, Jena University Hospital, Jena (WM), Department of Intensive Care Medicine, HELIOS Hospital Bad Saarow, Bad Saarow (SPW), Department of Anaesthesiology and Operative Intensive Care Medicine, Charité Campus Virchow Klinikum and Campus Mitte, Charité University Medicine Berlin (JB), Centre for Anaesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany (JS).
authors.forename: Christine
authors.initials: C
authors.lastname: Kubulus
authors.forename: Kathrin
authors.initials: K
authors.lastname: Schmitt
authors.forename: Noemi
authors.initials: N
authors.lastname: Albert
authors.forename: Alexander
authors.initials: A
authors.lastname: Raddatz
authors.forename: Stefan
authors.initials: S
authors.lastname: Gräber
authors.forename: Paul
authors.initials: P
authors.lastname: Kessler
authors.forename: Thorsten
authors.initials: T
authors.lastname: Steinfeldt
authors.forename: Thomas
authors.initials: T
authors.lastname: Standl
authors.forename: André
authors.initials: A
authors.lastname: Gottschalk
authors.forename: Winfried
authors.initials: W
authors.lastname: Meissner
authors.forename: Stefan P
authors.initials: SP
authors.lastname: Wirtz
authors.forename: Jürgen
authors.initials: J
authors.lastname: Birnbaum
authors.forename: Jan
authors.initials: J
authors.lastname: Stork
authors.forename: Thomas
authors.initials: T
authors.lastname: Volk
authors.forename: Hagen
authors.initials: H
authors.lastname: Bomberg
mesh_terms: D000328:Adult; D000368:Aged; D000765:Anesthesia, Conduction / Q000379:methods*; D001340:Autonomic Nerve Block / Q000379:methods*; D005260:Female; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000175:diagnosis / Q000517:prevention & control* / Q000523:psychology; D012042:Registries; D012189:Retrospective Studies; D014851:Wakefulness / Q000187:drug effects / Q000502:physiology
chemical_list: D006993:Hypnotics and Sedatives