Going local: could local and/or regional anaesthetic be an option for some procedures?

Transitioning from general to local anaesthetic (LA) for selected procedures may allow them to be performed outside of the operating theatre, in clean rooms (where the only anaesthesia that can be used is local, with the possible addition of some sedation). This would both reduce the wait for operating space for these procedures and potentially increase efficiencies by freeing up theatre space for other procedures. The box below includes examples of procedures that are possible candidates for this approach, and indeed already in use in some centres. Some changes may open the door to others; for example, where the first stage of testing for sacral neuromodulation (termed percutaneous nerve evaluation, PNE) is well established under LA, the second stage (battery implant) could lend itself to being performed under LA as well (Thompson et al., 2010). In carefully selected and fully counselled patients, tined lead insertion under LA could also be a consideration. Intra-urethral sphincteric Botox injections for voiding dysfunction can be delivered under LA in a clean room, taking them out of the main theatre suite. However, localisation of the sphincter needs to be guided by ultrasound or by concomitant urethral sphincter electromyography (EMG), if available.

Using regional anaesthesia (RA) for some procedures may also be an option to increase theatre capacity, as while this still requires the use of an operating theatre it deceases the interval required between cases – particularly during the COVID-19 era (Lie et al., 2020), where the aerosol generated by a general anaesthetic must be allowed to settle before the next case can commence.

There are important considerations to be aware of when considering a transition to local anaesthetic. Operating under local anaesthetic requires a different technique and specialised skills. Using sacral neuromodulation (SNM) as an example, highly experienced implanters are needed to minimise procedural interventions and ensure patient comfort during lead insertion and testing. Indeed, patient comfort should be the central consideration with the patient supported throughout the procedure by staff dedicated to do so.

Where and how can we perform the procedures?

Any clean room should be an option for a procedure under local anaesthetic where, in general, a sterile environment is still needed. A positive-pressure airflow system may be required, dependent on the procedure being performed. Technique should also be sterile to ensure patient safety.

In addition, day-case theatres in separate units might provide an option to move cases from busier centres to perform them under local or regional anaesthetic, freeing up theatre space. An added advantage of a day-case theatre is the reduced risk of being cancelled or delayed, in order to accommodate urgent procedures such as cancer surgery.

Some procedures – such as prolapse operations through the vagina – require as a minimum regional, rather than local, anaesthesia; in these cases, the operating theatre is still required, but the reduction in aerosol generation and the consequent time saved is an important consideration.

Further, some procedures may require general anaesthetic but could still be conducted as day cases. Laparoscopic ventral rectopexy has previously been conducted with same-day discharge with a high success rate – a single-centre UK study found 90% of patients were discharged within a day of the procedure (Powar et al., 2013). This approach could offer another route to reducing the burden on operating theatres.

Consideration should be given to the type of anaesthetic to be used: for example, spinal anaesthetic can cause urinary retention, so it is not appropriate for all patients. There is always a chance that the patient may have to be put under a general anaesthetic, so the patient will still need to be assessed and prepared accordingly. In the current situation patients need to be swabbed for COVID-19 and have a negative test result.

What else should be considered in switching to local or regional anaesthetic?

Provision of anaesthetic team support can be a challenge. Fentanyl is a preferred IV pain relief option for some procedures when procedures are being conducted under local anaesthetic, but must be administered by a trained specialist (for example, a specially trained nurse). In the past, where sedation was not planned, there have been challenges in securing the assignment of specialist anaesthetic nurses. Such assignments could be beneficial to staff, offering them the chance to gain experience and help to set up new services.

Dialogue with the pharmacy to ensure such medications are available can be lengthy: in order to minimise disruption, these should be prioritised.

A mentoring programme could help to support Trusts and clinicians to make the switch where appropriate, without compromising patient safety or wellbeing. Once the switch has taken place, the service should be audited to ensure patients are comfortable and procedures are being conducted appropriately.