Awake regional vs. combined general/regional anesthesia

Assuming the operative area is to be blocked for postoperative analgesia, a consequent dilemma is whether to use the block as the primary anesthesia for surgery, or to combine the block with general anesthesia. Many centres have a culture of performing surgery awake or under light sedation whenever possible. The reality is that little research has been conducted on this issue. Performing a regional block (cf. not performing a block) and therefore avoiding opioids is probably the critical factor in determining a patient's immediate postoperative experience. Whether a regional block is supplemented with propofol sedation/GA probably has only a minor additional  effect. In our practice, the decision to conduct surgery awake or under GA is determined by patient and provider factors.

Advantages/disadvantages of each approach:

1. Patient preference

a.  Awake: patient can observe surgery/monitors; fully awake immediately after surgery; reduced risk of nausea/vomiting.

b.  Asleep: eliminates intraoperative anxiety, uncomfortable patient position e.g. sitting/lateral position or prolonged surgery.

2. Anesthesiologist/Surgeon preference

a.    Awake: eliminates intraoperative GA risks e.g. difficult airway

b.    Asleep: accelerates surgical anesthesia e.g. sciatic block (onset time up to 60 min) - this decision depends significantly on the operating room set up e.g. availability of a "block room" and a second anesthesiologist who is able to get the block set up in the next patient. 

The following represents our approach according to each surgical procedure:

Shoulder surgery: under GA because of the potential discomfort associated with the steep sitting position and claustrophobic drapes.

Elbow surgery: awake if supine; GA if lateral (patient discomfort)

Wrist/Hand surgery: awake unless prolonged (> 2hr) surgery

Hip surgery: GA for patient comfort (lateral position, noise, invasive pelvic instrumentation)

Knee surgery: GA to accelerate surgical anesthesia.

Foot/Ankle surgery: GA to accelerate surgical anesthesia.