The influence of anesthetic techniques on postoperative cognitive function in elderly patients undergoing hip fracture surgery: General vs spinal anesthesia

The association between diabetes mellitus and postoperative cognitive dysfunction: a systematic review and meta-analysis

BACKGROUND

Postoperative cognitive dysfunction (POCD) is a typical consequence following surgery, particularly in cardiac surgeries. Despite its high incidence, the underlying etiology remains unclear. While diabetes mellitus (DM) has been associated with cognitive impairment, its specific function in POCD development remains unidentified. This study aims to evaluate the connection between DM and the risk of POCD.

METHODS

We conducted a comprehensive search of PubMed, Embase, Web of Science, and the Cochrane Library databases for studies of DM and risk with POCD, collecting data up to 14 September 2023. We assessed publication bias, heterogeneity, and study quality, adhering to PRISMA and AMSTAR guidelines.

RESULTS

Our study comprised 38 trials involving 8748 individuals, with 7734 patients undergoing follow-up. The pooled results showed that individuals with DM had an increased incidence of POCD compared to nondiabetic individuals (RR: 1.44, 95% CI: 1.26-1.65). The incidence of POCD was significantly higher in the group of patients with an average age older than 65 years (RR: 1.69, 95% CI: 1.30-2.20) compared with diabetic patients with an average age younger than 65 years (RR: 1.29, 95% CI: 1.09-1.64). Compared with diabetic patients undergoing cardiac surgery (RR: 1.33, 95% CI: 1.15-1.53), patients receiving non-cardiac surgery showed a greater incidence of POCD (RR: 2.01, 95% CI: 1.43-2.84).

CONCLUSION

Current evidence underscores that diabetic patients face a significantly higher risk of POCD compared to their nondiabetic counterparts. Further research is warranted to clarify the precise mechanisms of this relationship and explore potential preventive strategies for diabetic patients.

The impact of spinal versus general anesthesia on the variability of surgical times: a systematic review and meta-analysis

BACKGROUND

With spinal anesthesia, when cases are taking longer than usual, there may be behavioural tendencies for surgical teams to work more quickly. We conducted a systematic review with meta-analysis to examine standard deviations of surgical times for single-dose spinal anesthetics versus general anesthesia. We compared ratios of mean surgical times as a secondary endpoint.

METHODS

We included randomized trials of humans where general or spinal anesthesia was used for one category of surgical procedure (e.g., hip arthroplasty) and the article reported the means and standard deviations of operative durations. We used statistical methods suitable for surgical times following log-normal distributions. We used generalized confidence intervals to calculate point estimates of ratios and standard errors for each study, followed by pooling among studies using DerSimonian and Laird random-effects meta-analysis with Knapp-Hartung adjustment.

RESULTS

Among the 77 included studies, 96% were of high quality for our endpoint (i.e., had a low risk of bias), as no (0%) study focused on comparing variability of surgical times and none had surgical time as the primary endpoint. Spinal anesthesia was associated with 6.6% smaller standard deviations than general anesthesia (95% confidence interval, 15.8% smaller to 1.9% larger, P = 0.13). By meta-regression, there was no significant association of the ratios of standard deviations with study quality (P = 0.39), year of publication (P = 0.76), or categories of procedures (all five P ≥ 0.28). Spinal anesthesia was associated with 1.1% smaller means than general anesthesia (95% confidence interval, 3.7% smaller to 1.5% larger, P = 0.42). There were no significant associations between the ratios of means and study quality (P = 0.47), year of publication (P = 0.95), or categories of procedures (all five, P ≥ 0.63).

CONCLUSIONS

The results of this systematic review and meta-analysis show with high confidence that the effect of choosing spinal anesthesia on variability in surgical time, if present, is sufficiently small to have no substantive direct economic effect. The same conclusion applies to mean surgical time. Therefore, although anesthetic choice has a clinical (biological) impact and affects anesthesia times, the direct effects on surgical times and workflow are minimal at most. Anesthetic choice does not influence operating theatre productivity via changes to surgical times. The impact of spinal anesthetic effects is limited to nonoperative times (e.g., reducing anesthesia-controlled times by using a block room before the patient enters the operating room).

STUDY REGISTRATION

PROSPERO ( CRD42023461952 ); first submitted 8 September 2023.

The potential risk factors of postoperative cognitive dysfunction for endovascular therapy in acute ischemic stroke with general anesthesia

Background

Postoperative cognitive dysfunction (POCD) frequently occurs following endovascular therapy for acute ischemic stroke (AIS). Given the complexity of predicting AIS clinically, there is a pressing need to develop a preemptive prediction model and investigate the impact of anesthesia depth on AIS.

Methods

A total of 333 patients diagnosed with AIS were included in the study, comprising individuals with non-POCD (n = 232) or POCD (n = 101). Univariate and multivariate logistic regression analyses were utilized to examine the independent risk factors associated with POCD. A calibration, decision curve analysis, and precision-recall curves were employed to assess the model's goodness of fit.

Results

Multivariate regression analysis identified two inflammatory indicators, high-sensitivity C reactive protein (hs-CRP) and systemic immune inflammatory index (SII), and three brain injury indicators, National Institute of Health Stroke Scale (NIHSS) score, N-terminal pro-brain natriuretic peptide (NT-proBNP), and soluble protein-100 β (S100-β), which were used to construct a nomogram model.

Conclusion

The composite predictive model incorporating NIHSS score, hs-CRP, SII, NT-proBNP, and S100-β demonstrated efficacy in predicting POCD following AIS. Additionally, our results suggest a potential association between depth of anesthesia, cognitive impairment, and inflammatory response in AIS patients.

Analysis of the effect of mini-nutrition nursing plus Baduanjin rehabilitation exercise on fracture healing, mobility and nutritional status of elderly patients with vertebral or hip fractures

Hip fractures (VOHF) are a type of bone fracture that occurs in the hip bone, typically affecting older adults. Recovery from hip fractures in older adults can be challenging due to factors such as decreased mobility, weakened bones, and other health issues. This paper intends to determine the effect of mini-nutrition nursing plus Baduanjin rehabilitation exercise on postoperative rehabilitation of elderly patients with vertebral or hip fractures (VOHF). 106 senile VOHF patients were chosen for the study between May 2020 and May 2022. The research group (RG) consisted of 60 patients who received mini-nutrition nursing + Baduanjin rehabilitation exercise, while the control group (CG) had 46 patients who received mini-nutrition nursing + routine rehabilitation training. The study compared the fracture healing effect, MAMC, CC, and MNA-SF scores. The rehabilitation status of patients was evaluated using FMA, BI, BBS, and VAS. Adverse reactions during hospitalization and SF-36 scores were also recorded. Better fracture healing efficacy and higher MAMC, CC, and MNA-SF scores were determined in RG versus CG (P < 0.05). Elevated FMA, BI and BBS scores were observed in both groups after rehabilitation training, with more evident elevations in RG; while the VAS score reduced markedly and was lower in RG compared with CG (P < 0.05). In addition, RG was observed with fewer adverse reactions and higher SF-36 scores (P < 0.05). Mini-nutrition nursing + Baduanjin rehabilitation exercise can effectively accelerate the postoperative rehabilitation of elderly patients with VOHF, improve mobility, and enhance their quality of life.

Microbiota-gut-brain axis in perioperative neurocognitive and depressive disorders: Pathogenesis to treatment

An increasing number of people undergo anesthesia and surgery. Perioperative neurocognitive and depressive disorders are common central nervous system complications with similar pathogeneses. These conditions pose a deleterious threat to human health and a significant societal burden. In recent years, numerous studies have focused on the role of the gut microbiota and its metabolites in the central nervous system via the gut-brain axis. Its involvement in perioperative neurocognitive and depressive disorders has attracted considerable attention. This review aimed to elucidate the role of the gut microbiota and its metabolites in the pathogenesis of perioperative neurocognitive and depressive disorders, as well as the value of targeted interventions and treatments.

Effect of different anesthetic modalities on postoperative delirium in elderly hip fractures: A meta-analysis

BACKGROUND

Previous findings on the effect of general versus spinal anesthesia on postoperative delirium in elderly people with hip fractures are somewhat controversial. This article included the latest randomized controlled study for meta-analysis to evaluate the effect of general anesthesia (GA) and spinal anesthesia (SA) on delirium after hip fracture surgery in the elderly, so as to guide the clinical.

METHODS

Cochrane Library, PubMed, Web Of Science, and Embase were searched from inception up to January 16, 2024. Randomized controlled trial (RCT) was included to evaluate the postoperative results of GA and SA in elderly patients (≥50 years old) undergoing hip fracture surgery. Two researchers independently screened for inclusion in the study and extracted data. Heterogeneity was assessed by the I²and Chi-square tests, and P < .1 or I² ≥ 50% indicated marked heterogeneity among studies. The Mantel-Haenszel method was used to estimate the combined relative risk ratio (RR) and the corresponding 95% confidence interval (CI) for the binary variables.

RESULTS

Nine randomized controlled trials were included. There was no significant difference (RR = 0.93, 95% CI = 0.774-1.111, P > .05) in the incidence of postoperative delirium between the GA group and the SA group. In intraoperative blood transfusion (RR = 1.0, 95% CI = 0.77-1.28, Z = 0.04, P = .971), pulmonary embolism (RR = 0.795, 95% CI = 0.332-1.904, Z = 0.59, P = .606), pneumonia (RR = 1.47, 95% CI = 0.75-2.87, P = .675), myocardial infarction (RR = 0.97, 95% CI = 0.24-3.86, Z = 0.05, P = .961), heart failure (RR = 0.80, 95% CI = 0.26-2.42, Z = 0.40, P = .961), urinary retention (RR = 1.42, 95% CI = 0.77-2.61, Z = 1.11, P = .267) were similar between the 2 anesthetic techniques.

CONCLUSION

There is no significant difference in the effect of GA and SA on postoperative delirium in elderly patients with hip fracture, and their effects on postoperative complications are similar.

Comparing perioperative outcomes between regional anesthesia and general anesthesia in patients undergoing hip fracture surgery: a systematic review and meta-analysis

PURPOSE

Nearly all patients with hip fractures undergo surgical treatment. The use of different anesthesia techniques during surgery may influence the clinical outcomes. The optimal anesthetic technique for patients undergoing hip fracture surgery is still controversial. We performed this updated systematic review and meta-analysis to compare clinical outcomes of patients undergoing hip fracture surgery with different anesthesia techniques.

SOURCE

Articles published from 2000 to May 2023 were included from MEDLINE, Embase, Web of Science, and the Cochrane Library. We included randomized controlled trials and observational studies comparing general anesthesia (GA) with regional anesthesia (RA) for the outcomes of 30-day mortality, 90-day mortality, in-hospital mortality, perioperative complications, length of hospital stay, and length of surgery in patients undergoing hip fracture surgery. Subgroup analyses were performed for the outcomes based on study design (randomized controlled trials or observational studies). We used a random-effects model for all analyses.

PRINCIPAL FINDINGS

In this meta-analysis, we included 12 randomized controlled trials. There was no difference in postoperative 30-day mortality between the two groups (odds ratio [OR], 0.88; 95% confidence interval [CI], 0.44 to 1.74; I2 = 0%). The incidence of intraoperative hypotension was lower in patients who received RA vs GA (OR, 0.52; 95% CI, 0.38 to 0.72; I2 = 0%). No significant differences were observed in 90-day mortality, in-hospital mortality, postoperative delirium, pneumonia, myocardial infarction, venous thromboembolism, length of surgery, and length of hospital stay.

CONCLUSION

In this updated systematic review and meta-analysis, RA did not reduce postoperative 30-day mortality in hip fracture surgery patients compared to GA. Fewer patients receiving RA had intraoperative hypotension than those receiving GA did. Apart from intraoperative hypotension, the data showed no differences in complications between the two anesthetic techniques.

STUDY REGISTRATION

PROSPERO (CRD42023411854); registered 7 April 2023.

Anesthesia, Anesthetics, and Postoperative Cognitive Dysfunction in Elderly Patients

Postoperative cognitive dysfunction (POCD) remains a major issue that worsens the prognosis of elderly surgery patients. This article reviews the current research on the effect of different anesthesia methods and commonly utilized anesthetics on the incidence of POCD in elderly patients, aiming to provide an understanding of the underlying mechanisms contributing to this condition and facilitate the development of more reasonable anesthesia protocols, ultimately reducing the incidence of POCD in elderly surgery patients.

Comparison of the Analgesic Efficacy between Levobupivacaine 0.25% and Ropivacaine 0.375% for PENG (Pericapsular Nerve Group) Block in the Context of Hip Fracture Surgery of Elderly Patients: A Single-Center, Randomized, and Controlled Clinical Trial

Previous studies have compared levobupivacaine versus ropivacaine in various peripheral nerve blocks in terms of block duration, quality of analgesia, and onset time, but this has not occurred in the PENG block. Here, a single-center, randomized, and controlled clinical trial is presented. One hundred and twenty patients older than 65 years suffering from hip fractures and surgically treated at our institution under spinal anesthesia were eligible for participation; of them, one hundred and eight were analyzed. Patients were randomized to receive ultrasound-guided PENG blocks using 20 mL of either 0.25% levobupivacaine or 0.375% ropivacaine (both of which are equipotent concentrations). The primary endpoint was to compare the analgesic duration (time to first rescue) and analgesic quality (pain scores using the VAS, PAINAD, and AlgoPlus scales) between the groups. Secondary endpoints included comparing the onset time, describing the need for and type of rescue analgesics, and possible associated adverse effects. There were no statistically significant differences in analgesic duration between levobupivacaine (median 861.0, IQR 960) and ropivacaine (median 1205.0, IQR 1379; p = 0.069). Likewise, the quality of analgesia and onset time were comparable among the groups. A small number of patients required opioids as rescue analgesics (4.6%). The possible associated adverse effects included postoperative infection (11.1%) and delirium (2.8%).

Improved outcomes for spinal versus general anesthesia for hip fracture surgery: a retrospective cohort study of the National Surgical Quality Improvement Program

BACKGROUND

There is a lack of consensus in the literature as to whether anesthetic modality influences perioperative complications in hip fracture surgery. The aim of the present study was to assess the effect of spinal anesthesia compared with general anesthesia on postoperative morbidity and mortality in patients who underwent hip fracture surgery using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).

METHODS

We used the ACS NSQIP to identify patients aged 50 and older who received either spinal or general anesthesia for hip fracture surgery from 2016 to 2019. Propensity-score matching was performed to control for clinically relevant covariates. The primary outcome of interest was the combined incidence of stroke, myocardial infarction (MI) or death within 30 days. Secondary outcomes included 30-day mortality, hospital length of stay and operative time.

RESULTS

Among the 40 527 patients aged 50 and over who received either spinal or general anesthesia for hip fracture surgery from 2016 to 2019, 7358 spinal anesthesia cases were matched to general anesthesia cases. General anesthesia was associated with a higher incidence of combined 30-day stroke, MI or death compared with spinal anesthesia (OR 1.219 (95% CI 1.076 to 1.381); p=0.002). General anesthesia was also associated with a higher frequency of 30-day mortality (OR 1.276 (95% CI 1.099 to 1.481); p=0.001) and longer operative time (64.73 vs 60.28 min; p<0.001). Spinal anesthesia had a longer average hospital length of stay (6.29 vs 5.73 days; p=0.001).

CONCLUSION

Our propensity-matched analysis suggests that spinal anesthesia as compared with general anesthesia is associated with lower postoperative morbidity and mortality in patients undergoing hip fracture surgery.

The Analysis of Multiple Outcomes between General and Regional Anesthesia in Hip Fracture Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Surgical interventions in hip fracture have been associated with multiple adverse events, including perioperative hypotension and mortality, making the choice of the anesthetic method for this procedure crucial. There is still no consensus on whether regional (RA) or general (GA) anesthesia should be used to maintain hemodynamic stability and more favorable outcomes. Therefore, this meta-analysis examines the differences between RA and GA groups in the incidence of mortality, intraoperative hypotension, and other intra- and postoperative complications. The comparison is essential given the rising global prevalence of hip fractures and the need to optimize anesthesia strategies for improved patient outcomes, particularly in an aging population. We followed PRISMA guidelines (PROSPERO #CRD42022320413). We conducted the search for studies published in English before March 2022 in PubMed, Google Scholar, and the Cochrane Library. We included RCTs that compared general and regional anesthesia in adult patients having hip fracture surgical interventions. The primary outcome was perioperative mortality. The secondary outcomes were peri- or postoperative complications and duration of hospital stay. We conducted a meta-analysis in RevMan (version 5.4). We examined the quality of the methodology with the Cochrane risk of bias 2 tool, while the quality of evidence was determined with GRADE. Fifteen studies with 4110 patients were included. Our findings revealed no significant difference between general and regional anesthesia in risk of perioperative mortality (RR = 1.42 [0.96, 2.10], p-value = 0.08), intraoperative complications, or duration of hospital length of stay. Our results suggest that regional anesthesia and general anesthesia have comparable safety and can be used as alternatives based on specific patient requirements.

Comparing the Effect of Spinal and General Anesthesia for Hip Fracture Surgery in Older Patients: A Meta-analysis of Randomized Clinical Trials

OBJECTIVE

Hip fractures are the most common fractures among older adults, with most patients undergoing surgery. The debate regarding the type of anesthetic technique for hip fracture surgery is still ongoing. This meta-analysis aimed to compare the intraoperative and postoperative outcomes of spinal and general anesthesia in older patients undergoing hip fracture surgery.

METHODS

Eligible studies that compared the effects of spinal and general anesthesia were systematically searched from PubMed, Embase, and the Cochrane Library until May 27, 2022. The intraoperative and postoperative outcomes of the two anesthesia techniques were compared. Quality assessment, heterogeneity analysis, and publication bias of the studies were also assessed.

RESULTS

Nine articles of methodological quality were included in the meta-analysis. The pooled results revealed that there were significant differences in hypotension (risk ratio [RR] (95% confidence interval [CI]) = 0.81 (0.68, 0.97), p = 0.02) and ephedrine dose (weighted mean difference [WMD] [95%CI] = -20.94 [-37.50, -4.37] mg, p = 0.01) between the spinal and general anesthesia groups. However, no significant differences were observed in the use of ephedrine (RR [95% CI] = 0.77 [0.19, 3.05]), blood loss (WMD [95%CI] = -34.38 [-89.56, 20.80) mL], myocardial infarction (RR [95% CI] = 0.78 [0.31, 1.94] mL), heart failure (RR [95% CI] = 0.87 [0.17, 4.36] mL), stroke (RR [95%CI) = 0.65 [0.22, 1.95] mL), postoperative nausea and vomiting (RR [95% CI] = 0.88 [0.17, 4.35] mL), delirium (RR [95% CI] = 1.08 [0.89, 1.31] mL), and mortality (RR [95% CI] = 1.10 [0.72, 1.68] mL) (all p < 0.05). No publication bias was observed in any of the included studies.

CONCLUSION

Compared to general anesthesia, spinal anesthesia was associated with a lower risk of intraoperative hypotension and lower doses of ephedrine in older patients undergoing hip fracture surgery.

Lumboperitoneal Shunt Surgery under Spinal Anesthesia on Idiopathic Normal Pressure Hydrocephalus Patients

Since the publication of guidelines for managing idiopathic normal pressure hydrocephalus (iNPH) in 2004, an increasing number of patients with iNPH have been undergoing shunt surgery in Japan. However, shunt surgeries for iNPH can be challenging because the procedures are performed on elderly patients. General anesthesia-related risks, such as postoperative pneumonia or delirium, are higher in the elderly. To decrease these risks, we applied spinal anesthesia on a lumboperitoneal shunt (LPS). Herein, we analyzed our methods focusing on the postoperative outcomes. We retrospectively analyzed 79 patients who underwent LPS at our institution with more than one year of follow-up. The patients were divided into two groups based on the anesthetic approach, that is, 1) general anesthesia and 2) spinal anesthesia, and were examined in terms of postoperative complications, delirium, and postoperative hospital stay. In the general anesthesia group, two patients had respiratory complications after the surgery. The postoperative delirium score using the intensive care delirium screening checklist (ICDSC) was 0 (2) (median [interquartile range]), and the length of postoperative hospital stay was 11 (4) days. In the spinal anesthesia group, no patients had respiratory complications. The postoperative mean ICDSC was 0 (1), and the length of postoperative hospital stay was 10 (3) days. Although there was no significant difference regarding postoperative delirium existed, LPS under spinal anesthesia decreased respiratory complications and significantly shortened the postoperative hospital stay. LPS under spinal anesthesia could be an alternative to general anesthesia in elderly patients with iNPH and possibly lessen the general anesthesia-related risks.

Effects of surgical treatment modalities on postoperative cognitive function and delirium in elderly patients with extremely unstable hip fractures

BACKGROUND

As the perioperative risk of elderly patients with extremely unstable hip fractures (EUHFs) is relatively high and therapeutic effect is not satisfactory, new thera-peutic strategies need to be proposed urgently to improve the efficacy and clinical outcomes of such patients.

AIM

To determine the influence of two surgical treatment modalities on postoperative cognitive function (CF) and delirium in elderly patients with EUHFs.

METHODS

A total of 60 elderly patients consecutively diagnosed with EUHF between September 2020 and January 2022 in the Chongqing University Three Gorges Hospital were included. Of them, 30 patients received conventional treatment (control group; general consultation + fracture type-guided internal fixation), and the other 30 received novel treatment (research group; perioperative multidisciplinary treatment diagnosis and treatment + individualized surgical plan + risk prediction). Information on hip function [Harris hip score (HHS)], perioperative risk of orthopedic surgery [Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM)], CF [Montreal cognitive assessment scale (MoCA)], postoperative delirium [mini-cognitive (Mini-Cog)], adverse events (AEs; internal fixation failure, infection, nonunion, malunion, and postoperative delirium), and clinical indicators [operation time (OT), postoperative hospital length of stay (HLOS), ambulation time, and intraoperative blood loss (IBL)] were collected from both groups for comparative analyses.

RESULTS

The HHS scores were similar between both groups. The POSSUM score at 6 mo after surgery was significantly lower in the research group compared with the control group, and MoCA and Mini-Cog scores were statistically higher. In addition, the overall postoperative complication rate was significantly lower in the research than in the control group, including reduced OT, postoperative HLOS, ambulation time, and IBL.

CONCLUSION

The new treatment modality has more clinical advantages over the conventional treatment, such as less IBL, faster functional recovery, more effectively optimized perioperative quality control, improved postoperative CF, mitigated postoperative delirium, and reduced operation-related AEs.

Neuraxial versus general anesthesia in elderly patients undergoing hip fracture surgery and the incidence of postoperative delirium: a systematic review and stratified meta-analysis

BACKGROUND

Evidence-based effect of anesthetic regimens on postoperative delirium (POD) incidence after hip fracture surgery is still debated. Randomized trials have reported inconsistent contradictory results largely attributed to small sample size, use of outdated drugs and techniques, and inconsistent definitions of adverse outcomes. The primary objective of this meta-analysis was to investigate the impact of different anesthesia regimens on POD, cognitive impairment, and associated complications including mortality, duration of hospital stay, and rehabilitation capacity.

METHODS

We identified randomized controlled trials (RCTs) published from 2000 to December 2021, in English and non-English language, comparing the effect of neuraxial anesthesia (NA) versus general anesthesia (GA) in elderly patients undergoing hip fracture surgery, from PubMed, EMBASE, Google Scholar, Web of Science and the Cochrane Library database. They were included if POD incidence, cognitive impairment, mortality, duration of hospital stay, or rehabilitation capacity were reported as at least one of the outcomes. Study protocols, case reports, audits, editorials, commentaries, conference reports, and abstracts were excluded. Two investigators (KYC and TXY) independently screened studies for inclusion and performed data extraction. The risk of bias was assessed using the Cochrane Collaboration risk-of-bias tool. The quality of the evidence for each outcome according to the GRADE working group criteria. The odds ratio (OR) and 95% confidence intervals (CI) were calculated to assess the pooled data.

RESULTS

A total of 10 RCTs with 3968 patients were included in the present analysis. No significant differences were found in the incidence of POD comparing NA vs GA [OR 1.10, 95% CI (0.89 to 1.37)], with or without including patients with a pre-existing condition of dementia or delirium, POD incidence from postoperative day 2-7 [OR 0.31, 95% CI (0.06 to -1.63)], in mini-mental state examination (MMSE) score [OR 0.07, 95% CI (-0.22 to 0.36)], or other neuropsychological test results. NA appeared to have a shorter duration of hospital stay, especially in patients without pre-existing dementia or delirium, however the observed effect did not reach statistical significance [OR -0.23, 95% CI (-0.46 to 0.01)]. There was no difference in other outcomes, including postoperative pain control, discharge to same preadmission residence [OR 1.05, 95% CI (0.85 to 1.31)], in-hospital mortality [OR 1.98, 95% CI (0.20 to 19.25)], 30-day [OR 1.03, 95% CI (0.47 to 2.25)] or 90-day mortality [OR 1.08, 95% CI (0.53-2.24)].

CONCLUSIONS

No significant differences were detected in incidence of POD, nor in other delirium-related outcomes between NA and GA groups and in subgroup analyses. NA appeared to be associated with a shorter hospital stay, especially in patients without pre-existing dementia, but the observed effect did not reach statistical significance. Further larger prospective randomized trials investigating POD incidence and its duration and addressing long-term clinical outcomes are indicated to rule out important differences between different methods of anesthesia for hip surgery.

TRIAL REGISTRATION

10.17605/OSF.IO/3DJ6C.

Impact of Anesthesia selection on Post-Op Pain Management in Operatively treated Hip Fractures

OBJECTIVES

To determine if the use of Peripheral Nerve Block (PNB) versus Local Infiltration Analgesia (LIA) for hip fracture patients, affected opioid consumption in the early post-operative period.

DESIGN

Retrospective cohort study SETTING: Two level 1 trauma centers PATIENTS/INTERVENTION: 588 patients with surgically treated AO/OTA 31A and 31B fractures between February 2016-October 2017 were included. 415 (70.6%) received general anesthesia (GA) alone, 152 received GA plus perioperative PNB (25.9%), and 21 had GA plus LIA intra-operatively (3.6%). Median age was 82 years; predominantly female (67%) and AO/OTA 31A fractures (55.37%).

MAIN OUTCOME MEASURES

Morphine Milligram Equivalents (MME) at 24 and 48 hours postoperatively, length of stay (LOS) and the occurrence of any complication after surgery RESULTS: The PNB cohort was less likely to use any opioid than the GA group at 24 and 48 hours postoperatively (OR: 0.36, 95% CI: 0.22-0.61 and OR: 0.56, 95% CI: 0.35-0.89 respectively). LOS ≥ 10 days had 3.24 times the odds of 24- and 48-hour opioid administration compared to LOS ≤ 10 days (OR: 3.24, 95% CI 1.11-9.42; OR: 2.98, 95% CI 1.38-6.41, respectively). The most common complication was post-operative delirium, with PNB more likely to present with any complication compared to GA (OR= 1.88, 95% CI 1.09-3.26). There was no difference when comparing LIA to general anesthesia.

CONCLUSIONS

Our findings suggest PNB for hip fracture can help limit the use of post-operative opioids with adequate pain relief. Regional analgesia does not seem to avoid complications such as delirium.

Regional versus general anesthesia in older patients for hip fracture surgery: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The optimal anesthesia technique for older patients undergoing hip fracture surgery remains controversial. We performed a systematic review and meta-analysis of updated randomized controlled trials (RCTs) to assess whether regional anesthesia was superior to general anesthesia in hip fracture surgery.

METHODS

We searched PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials from January 2000 until April 2022. RCTs directly comparing regional and general anesthesia in hip fracture surgery were included in the analysis. The incidence of delirium and mortality were the primary outcomes and other perioperative outcomes including complications were secondary outcomes.

RESULTS

Thirteen studies involving 3736 patients were included in this study. There was no significant difference in the incidence of delirium (odds ratio [OR] 1.09; 95% confidence interval [CI] 0.86, 1.37) and mortality (OR 1.08; 95% CI 0.71, 1.64) between the two groups. Patients receiving regional anesthesia in hip fracture surgery were associated with a reduction in operative time (weighted mean difference [WMD]: - 4.74; 95% CI - 8.85, - 0.63), intraoperative blood loss (WMD: - 0.25; 95% CI - 0.37, - 0.12), postoperative pain score (WMD: - 1.77; 95% CI - 2.79, - 0.74), length of stay (WMD: - 0.10; 95% CI - 0.18, - 0.02), and risk of acute kidney injury (AKI) (OR 0.56; 95% CI 0.36, 0.87). No significant difference was observed in the other perioperative outcomes.

CONCLUSIONS

For older patients undergoing hip fracture surgery, RA did not significantly reduce the incidence of postoperative delirium and mortality compared to GA. Due to the limitations of this study, the evidence on delirium and mortality was still inconclusive and further high-quality studies are needed.

General Anesthesia Versus Regional Anesthesia in the Elderly Patients Undergoing Hip Fracture Surgeries: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND

Surgery is the preferred treatment option for the elderly patients with hip fractures. However, the choice of general anesthesia (GA) or regional anesthesia (RA) remains controversial. The quality of evidence has further improved with the advent of several high-quality randomized clinical trials (RCTs) in the last two years. The purpose of this study was to compare the clinical outcomes of two anesthetic techniques in elderly patients undergoing hip fracture surgeries.

METHODS

Eligible studies were identified from PubMed/MEDLINE, Web of Science, Scopus, EMBASE and reference lists from January 2000 to June 2022 in this current systematic review and meta-analysis. The outcomes included the surgery-related outcomes (duration of surgery, duration of anesthesia, intraoperative blood loss and number of transfusions) and postoperative outcomes (30-day mortality, postoperative delirium,cardiovascular events and other complications).

RESULTS

A total of 10 RCTs were included, and a total of 3594 patients were analyzed. RA was associated with shorter duration of surgery, shorter length of hospital stays and less intraoperative blood loss compared to GA. There were no significant differences between the two groups in the number of blood transfusions, duration of anesthesia, 30-day mortality or postoperative delirium.

CONCLUSIONS

Our pooled analysis identified no significant differences in terms of the safety between RA and GA, while RA reduces intraoperative blood loss, length of hospital stays and duration of surgery. These results suggest that RA appears to be preferable for the elderly patients with hip fractures.

Postoperative Delirium and Cognitive Dysfunction after General and Regional Anesthesia: A Systematic Review and Meta-Analysis

Background: Perioperative disorders of neurocognitive function are a set of heterogeneous conditions, which include transient post-operative delirium (POD) and more prolonged post-operative cognitive dysfunction (POCD). Since the number of annually performed surgical procedures is growing, we should identify which type of anesthesia is safer for preserving neurocognitive function. The purpose of this study was to compare the effect of general anesthesia (GA) and regional anesthesia (RA) in patients undergoing surgical procedures under general anesthesia and regional anesthesia. Material and methods: We searched for randomized controlled studies, which studied post-operative cognitive outcomes after general and regional anesthesia in the adult patient population. Results: Thirteen articles with 3633 patients: the RA group consisted of 1823 patients, and the GA group of 1810 patients, who were selected for meta-analysis. The overall effect of the model shows no difference between these two groups in terms of risk for post-operative delirium. The result is insensitive to the exclusion of any study. There was no difference between RA and GA in terms of post-operative cognitive dysfunction. Conclusions: There was no statistically significant difference between GA and RA in the incidence of POD. There was no statistically significant difference in the incidence of POCD per-protocol analysis, psychomotor/attention tests (preoperative/baseline, post-operative), memory tests (postoperatively, follow up), mini-mental state examination score 24 h postoperatively, post-operative reaction time three months postoperatively, controlled oral word association test, and digit copying test. There were no differences in the incidence of POCD in general and regional anesthesia at one week postoperatively, three months postoperatively, or total events (one week or three months). The incidence of post-operative mortality also did not differ between two groups.

Fascia iliaca compartment block can reduce the incidence of early post-operative cognitive impairment in elderly patients with high-risk hip replacement

Objective

In this study, we aimed to observe the effects of ultrasound-guided fascia iliaca compartment block (FICB) combined with hypobaric spinal anesthesia on post-operative pain and cognitive function in elderly patients with high-risk hip replacement.

Methods

A total of 84 elderly patients-aged 65-85 years, with American Society of Anesthesiologists physical status III-IV, and scheduled for hip arthroplasty between September 2021 and May 2022-were selected. One or more organs with moderate to severe impairment were included in all patients. The patients were randomly divided into a hypobaric spinal anesthesia group (group C, control group) and an ultrasound-guided FICB combined with hypobaric spinal anesthesia group (group E, experimental group). Group C was given 3.5 mL of 0.32% ropivacaine hypobaric spinal anesthesia, and group E received ultrasound-guided FICB combined with 3.5 mL of 0.32% ropivacaine hypobaric spinal anesthesia. The patients were compared using the visual analog scale (VAS) for pain, Harris hip function score, and simple Mini-Mental State Examination (MMSE) scale. Blood β-amyloid (Aβ) and neuronal microtubule-associated protein (tau) levels were measured. We compared intraoperative conditions and post-operative complications between the two groups to assess the effects of FICB combined with hypobaric spinal anesthesia on post-operative pain and cognitive function in elderly patients with high-risk hip replacement.

Results

At 1 and 3 days after the operation, patients in group C had significantly higher VAS and lower MMES scores than those in group E. The differences were statistically significant at 1 (P < 0.01) and 3 (P < 0.05) days after the operation. At 1 day after operation, the Harris score of patients in group C was significantly lower than that of patients in group E (P < 0.05). The Aβ and tau levels of patients in group C were significantly higher than those of patients in group E at 1 day after the operation (P < 0.01). The Aβ levels of patients in group C were significantly higher than those of patients in group E at 3 days after the operation (P < 0.05). The intraoperative conditions and post-operative complication rates did not differ significantly between the two groups. At 1 day before and 5 days after the operation, there was no difference in any of the indicators.

Conclusion

By lowering pain and managing Aβ and tau protein concentrations, FICB can successfully lower the incidence of early post-operative cognitive impairment in elderly patients with high-risk hip replacement.

Clinical trial registration

www.chictr.org.cn, identifier: ChiCTR2100051162.

Perioperative considerations in patients with chemotherapy-induced cognitive impairment: a narrative review

Patients with cancer may suffer from a decline in their cognitive function after various cancer therapies, including surgery, radiation, and chemotherapy, and in some cases, this decline in cognitive function persists even years after completion of treatment. Chemobrain or chemotherapy-induced cognitive impairment, a well-established clinical syndrome, has become an increasing concern as the number of successfully treated cancer patients has increased significantly. Chemotherapy-induced cognitive impairment can originate from direct neurotoxicity, neuroinflammation, and oxidative stress, resulting in alterations in grey matter volume, white matter integrity, and brain connectivity. Surgery has been associated with exacerbating the inflammatory response associated with chemotherapy and predisposes patients to develop postoperative cognitive dysfunction. As the proportion of patients living longer after these therapies increases, the magnitude of impact and growing concern of post-treatment cognitive dysfunction in these patients has also come to the fore. We review the clinical presentation, potential mechanisms, predisposing factors, diagnostic methods, neuropsychological testing, and imaging findings of chemotherapy-induced cognitive impairment and its intersection with postoperative cognitive dysfunction.

Activation of astrocyte Gq pathway in hippocampal CA1 region attenuates anesthesia/surgery induced cognitive dysfunction in aged mice

The elderly are particularly vulnerable to brain dysfunction after fracture surgery, but the mechanism underlying the cognitive decline due to anesthesia/surgery is not well understood. In this study, we observed hippocampus-dependent cognitive impairment in aged mice undergoing anesthesia and tibial fracture surgery, a common model of postoperative cognitive dysfunction in aged mice. We used Golgi staining and neuroelectrophysiological techniques to detect structurally and functionally impaired synaptic plasticity in hippocampal CA1 region of Postoperative cognitive dysfunction aged mice, respectively. Based on the 'third party synapse' hypothesis of astrocytes, we used glial fibrillary acidic protein to label astrocytes and found an increase in abnormal activation of astrocytes in the CA1 region of hippocampus. We hypothesize that abnormal astrocyte function is the driving force for impaired synaptic plasticity. So we used chemogenetic methods to intervene astrocytes. Injection of adeno-associated virus into the CA1 region of the hippocampus bilateral to aged mice resulted in the specific expression of the Gq receptor, a receptor specially designed to be activated only by certain drugs, within astrocytes. The results of novel object recognition and conditioned fear experiments showed that CNO activation of astrocyte Gq pathway could improve the learning and memory ability and the synaptic plasticity of Postoperative cognitive dysfunction aged mice was also improved. The results of this study suggest that activation of the Gq pathway in astrocytes alleviates Postoperative cognitive dysfunction induced by anesthesia and surgery in aged mice.

Clinical effectiveness and safety of spinal anaesthesia compared with general anaesthesia in patients undergoing hip fracture surgery using a consensus-based core outcome set and patient-and public-informed outcomes: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

We conducted a systematic review and meta-analysis of contemporary RCTs to determine the clinical effectiveness of spinal vs general anaesthesia (SA vs GA) in patients undergoing hip fracture surgery using a consensus-based core outcome set, and outcomes defined as important by patient and public involvement (PPI) initiatives.

METHODS

RCTs comparing any of the core outcomes (mortality, time from injury to surgery, acute coronary syndrome, hypotension, acute kidney injury, delirium, pneumonia, orthogeriatric input, being out of bed at day 1 postoperatively, and pain) or PPI-defined outcomes (return to preoperative residence, quality of life, and mobility status) between SA and GA were identified from MEDLINE, Embase, Cochrane Library, and Web of Science (2000 to February 2022). Pooled relative risks (RRs) and mean differences (95% confidence intervals [CIs]) were estimated.

RESULTS

There was no significant difference in the risk of delirium comparing SA vs GA (RR=1.07; 95% CI, 0.90-1.29). Comparing SA vs GA, the RR for mortality was 0.56 (95% CI, 0.22-1.44) in-hospital, 1.07 (95% CI, 0.52-2.23) at 30 days, and 1.08 (95% CI, 0.55-2.12) at 90 days. Spinal anaesthesia reduced the risk of acute kidney injury compared with GA: RR=0.59 (95% CI, 0.39-0.89). There were no significant differences in the risk of other outcomes. Few studies reported PPI-defined outcomes, with most studies reporting on one to three core outcomes.

CONCLUSIONS

Except for acute kidney injury, there were no differences between SA and GA in hip fracture surgery when using a consensus-based core outcome set and patient and public involvement-defined outcomes. Most studies reported limited outcomes from the core outcome set, and few reported outcomes important to patients, which should be considered when designing future RCTs.

PROSPERO REGISTRATION

CRD42021275206.

The Incidence of Acute Respiratory Infection Was Higher in the Older Adults with Lower Limb Fracture Who Receive Spinal Anesthesia Than Those Who Receive General Anesthesia

INTRODUCTION

Acute respiratory infection (ARI) can significantly reduce postoperative quality of life and impair the recovery of older adult patients with lower-limb fractures, and its relationship with methods of anesthesia remains inconclusive. Using data from the National Health Insurance Research Database (NHIRD) of Taiwan, this study examined the data of patients who received surgical management for lower-limb fractures and compared those who underwent general anesthesia (GA) with those who underwent regional anesthesia (RA) in terms of their incidence of acute upper and lower respiratory infection during the one-month postoperative period. The study also identified related risk factors.

MATERIAL AND METHODS

Approximately two million patients were randomly sampled from the NHIRD registry. We identified and enrolled patients with lower-limb fractures who were over 60 years old and underwent GA or RA during surgeries conducted between 2010 and 2017. We divided these patients into two groups for further analysis. The outcome of this study was the development of ARI during the one-month postoperative period.

RESULTS

In total, 45,032 patients (GA group, 19,580 patients; RA group, 25,452 patients) with a mean age of 75.0 ± 8.9 years were included in our study. The incidence of postoperative ARI within one month of surgery was 8.0% (1562 patients) in the GA group and 9.5% (2412 patients) in the RA group, revealing a significant difference. The significant risk factors for the incidence of ARI were the application of RA for surgery, older age, hypertension, liver disease, and chronic obstructive pulmonary disease (COPD). A subgroup analysis revealed that the RA method was associated with a significantly higher ARI incidence relative to the GA method among patients aged between 60 and 80 years, among male patients, among the patients with or without any comorbidity and among the patients without COPD.

CONCLUSION

The incidence of postoperative ARI within one month of surgery was higher among older patients with lower-limb fractures who received RA for surgery than among those who received GA for surgery. The other major risk factors for ARI were older age, hypertension, liver disease, and COPD. Therefore, we should focus on patients with a high risk of developing ARI, especially during the COVID-19 pandemic.

The impact of regional versus general anesthesia on postoperative neurocognitive outcomes in elderly patients undergoing hip fracture surgery: A systematic review and meta-analysis

BACKGROUND

Randomized trials have shown conflicting results regarding differences in outcomes according to anesthesia type on the prevalence of postoperative delirium (POD) or postoperative cognitive dysfunction (POCD) in hip surgery patients. The aim of this Meta analysis is to compare the effect of general and regional anesthesia in older patients undergoing hip fracture surgery.

METHODS

A literature search for meta-analysis was performed using Pubmed, The Cochrane Library, Embase and Web of Science citation index for randomized controlled trials (RCTs) to compare the regional anesthesia (RA) to general anesthesia (GA) for postoperative outcomes in elderly undergoing hip fracture surgery till June 2022. The primary outcomes were the incidence of POD or POCD at 24 h, 3 days and 7 days postoperatively. The secondary outcomes were 30 days mortality rate and other adverse events. The risk of bias was assessed using the Cochrane methodology.

RESULTS

Eight studies including 3555 elderly patients over 65 years old showed that there was no significant difference in the prevalence of POD or POCD between RA and GA at 24 h [OR 0.73; 95% coincidence interval (CI) 0.19, 2.71, I2 = 53%; n = 452; P = 0.63], at 3 days [OR 1.03; 95% CI 0.79, 1.35, I2 = 0%; n = 1362; P = 0.82], at 7 days [OR 0.79; 95% CI 0.41, 1.52, I2 = 51%; n = 1336; P = 0.47], respectively. No significant differences were observed in the incidence of other adverse events.

CONCLUSIONS

No significant difference was found in the incidence of cognitive dysfunction after either general or regional anesthesia in elderly patients. Our finding of similar outcomes at 24 h, 3 days and 7 days postoperatively with either technique suggests that anesthesia choices for hip-fracture surgery may be based on the individual characteristics of each patient rather than on anticipated differences in clinical outcomes.

Identification of individuals at risk for postoperative cognitive dysfunction (POCD)

Postoperative cognitive dysfunction (POCD) is common, occurring in around 10-54% of individuals within first few weeks after surgery. Although the majority of POCD is less commonly persistent later than 3 months following surgery, the condition increases length of stay (LOS), mortality and long-term cognitive decline, raising the need for a broad screening to identify individuals at risk for POCD during the perioperative period. In this narrative review, we summarize preoperative, intraoperative and postoperative risk factors for POCD reported in last 5 years and discuss neuropsychological tools and potential biomarkers and time points for assessment that might be suitable for clinical use. We aim to provide crucial information for developing a strategy of routine screening for POCD, which may assist with better identification of at-risk individuals for early interventions. Very importantly, the utilization of a standardized strategy may also allow higher consistency and comparability across different studies.

Clinical Observation of General Anesthesia Combined with Spinal Anesthesia in Elderly Patients with Chronic Obstructive Pulmonary Disease

Objective

This work is aimed at evaluating the efficacy and safety of general anesthesia (GA) combined with spinal anesthesia (SA) (GA+SA) in elderly patients with chronic obstructive pulmonary disease (COPD). Methods and Material. 50 elderly COPD patients were rolled randomly into a control group (simple GA) and observation group (GA+SA). The differences in operation time, postoperative recovery time (PRT), language expression time (LET), anesthetic dosage (AD), catheter extubation time (CET), respiratory circulation indicators (mean arterial pressure (MAP), heart rate (HR), SaO2, and PaO2), postoperative VRS score, pulmonary function (forced vital capacity (FVC)), forced expiratory volume in 1 s (FEV1)/FVC and forced expiratory flow (FEF 25%~75%), serum inflammatory factors (IL-6, IL-8, and TNF-α), Short Portable Mental Status Questionnaire (SPMSQ) score, and the incidence of respiratory system events were analyzed.

Results

The results showed that the PRT, LET, AD, and CET of the observation group were all shorter (P < 0.05). The postoperative MAP, HR, SaO2, and PaO2 levels of patients who received GA+SA were much higher than those who received simple GA (P < 0.05). The postoperative VRS score of the observation group was better than that of the controls (P < 0.05). The postoperative pulmonary function of patients in the observation group was better compared with that in the control group (P < 0.05). The postoperative serum inflammatory factors in the observation group were lower in contrast to the patients who received simple GA (P < 0.05). The postoperative cognitive function SPMSQ score of patients who received GA+SA was lower compared with the score of patients who received simple GA (P < 0.05). However, the probability of respiratory system events in the observation group was lower (P < 0.05).

Conclusion

In conclusion, GA+SA could significantly shorten the PRT and improve the recovery quality of elderly COPD patients. It can also reduce the postoperative inflammatory response and strengthen the pulmonary function and cognitive function. It also enhances the analgesic which is beneficial to patients' postoperative recovery. Therefore, GA+SA was a highly effective and safe anesthesia method for elderly patients with COPD, and it was worthy of clinical application.

Effect of regional anesthesia on the postoperative delirium: A systematic review and meta-analysis of randomized controlled trials

Objective

Postoperative delirium (POD) starts in the recovery room and occurs up to 5 days after surgery. However, the POD guidelines issued by the European Society of Anesthesiology (ESA) suggest that the effect of regional anesthesia on POD is controversial. This meta-analysis aims to investigate whether perioperative regional anesthesia reduced the incidence of POD.

Methods

Standard Published randomized controlled trails (RCTs) were searched from bibliographic databases to identify all evidence that reported regional anesthesia assessing incident delirium following diverse surgeries. The primary outcome was the incidence of POD, and the secondary outcomes were POD scores, pain scores, and emergence time. The relative risk (RR) for dichotomous outcomes and the weighted or standardized mean difference (WMD, SMD) for continuous outcomes were estimated using a random-effects model.

Results

Twenty RCTs with 2110 randomized participants undergoing different surgeries were included. Meta-analysis showed that regional anesthesia was associated with less POD incidence compared to general anesthesia (total intravenous anesthesia (TIVA) or inhalation anesthesia) (relative risk (RR) = 0.62, 95% confidence interval (CI) = 0.45–0.85)). Subgroup analysis showed that the decrease in POD incidence was associated with a nerve block (0.46, 95% CI = 0.32–0.67) and regional-combined-general anesthesia (0.42, 95% CI = 0.29–0.60). Regional anesthesia significantly reduced POD incidence in the recovery room after pediatric surgeries (0.41, 95% CI = 0.29–0.56). Regional anesthesia also reduced the POD score (SMD −0.93, 95% CI = −1.55 to −0.31) and pain score (SMD −0.95, 95% CI = −1.72 to −0.81). There was no significant difference in emergence time between regional anesthesia and general anesthesia (WMD −1.40, 95% CI = −3.83 to 6.63).

Conclusions

There was a significant correlation between regional anesthesia and the decrease in POD incidence, POD score, and pain score.

Observation of Anesthetic Effect of Dexmedetomidine Combined With Intraspinal Anesthesia in Hip Arthroplasty and its Effect on Postoperative Delirium and Stress Response

Objective

To observe the anesthetic effect of dexmedetomidine combined with spinal anesthesia in hip arthroplasty, and to analyze the effects of dexmedetomidine on postoperative stress response, incidence of delirium, immune function and inflammatory indicators.

Methods

A total of 42 patients who underwent hip replacement in our hospital from March 2020 to June 2021 were selected as the research subjects and randomly divided into the control group and the observation group, 21 cases in each group. The control group was given intraspinal anesthesia, and the observation group was given dexmedetomidine on this basis. The onset time and maintenance time of sensory and motor nerve block were recorded. Stress response indexes [cortisol (Cor), blood glucose (Glu), adrenaline (E), noadrenaline (NE)], T lymphocyte subsets (CD3+, CD4+, CD8+, CD4+/CD8+), inflammatory indexes [tumor necrosis factor -α (TNF-α) and interleukin-6 (IL-6)] were detected before and after operation, and the incidence of postoperative delirium in both groups was recorded.

Results

The onset time of sensory nerve block and motor block in the observation group were lower than those in the control group, and the retention time of sensory nerve block and motor nerve block were higher than those in the control group (P < 0.05). After surgery, the levels of Cor, Glu, E and NE in the observation group were lower than those in the control group (P < 0.05). After surgery, the incidence of postoperative delirium in the observation group (4.79%) was lower than that in the control group (28.57%) (P < 0.05). After surgery, the levels of CD3+, CD4+, CD8+, and CD4+/CD8+ in the observation group were higher than those in the control group (P < 0.05). After surgery, the levels of TNF-α and IL-6 in the observation group were lower than those in the control group (P < 0.05).

Conclusion

The combined use of dexmedetomidine and intraspinal anesthesia has good anesthesia effect in hip joint replacement, which can greatly reduce the stress response of patients, reduce the incidence of postoperative delirium, and effectively restore the immune function of patients, reduce the level of inflammatory response, and has high clinical application value.

Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment

Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.

The Effect of General Anesthesia vs. Regional Anesthesia on Postoperative Delirium-A Systematic Review and Meta-Analysis

Background

Postoperative delirium (POD) commonly occurs in patients following major surgeries and is associated with adverse prognosis. The modes of anesthesia may be associated with POD occurrence. General anesthesia (GA) causes loss of consciousness in the patient by altering the levels of some neurotransmitters as well as signaling pathways. We conducted this meta-analysis to investigate the effect of GA vs. regional anesthesia (RA) on POD incidence in surgical patients.

Methods

The databases of Pubmed, Embase, and Cochrane Library were searched till October 22, 2021. The eligible criteria were participants aged 18 years or older, patients undergoing surgery under GA and RA, and articles reporting the effect of GA vs. RA on POD incidence. RevMan 5.3 was used to perform statistical analyses.

Results

A total of 21 relevant trials with a total of 1,702,151 patients were included. The pooled result using random-effects model with OR demonstrated significant difference in POD incidence between patients with GA and RA (OR = 1.15, 95% CI: [1.02, 1.31], I² = 83%, p for effect = 0.02). We did not obtain the consistent pooled result after sensitivity analysis (OR = 0.95, 95% CI: [0.83, 1.08], I² =13%, p for effect = 0.44) and excluded the articles without the information on preoperative cognitive or neuropsychological assessment (OR = 1.12, 95% CI: [1.00, 1.25], I² =80%, p for effect = 0.05), respectively.

Conclusion

This meta-analysis could not identify that GA was significantly associated with POD occurrence in surgical patients compared with RA.

Cognitive Impairment Following Clinical or Recreational Use of Gammahydroxybutyric Acid (GHB): A Systematic Review

BACKGROUND

GHB (gamma-hydroxybutyric acid; sodium oxybate) is a general anaesthetic that is clinically used for the treatment of narcolepsy, cataplexy, alcohol withdrawal and alcohol relapse prevention. In addition, GHB is recreationally used. Most clinical and recreational users regard GHB as an innocent drug devoid of adverse effects, despite its high dependence potential and possible neurotoxic effects. At high doses, GHB may lead to a comatose state. This paper systematically reviews possible cognitive impairments due to clinical and recreational GHB use.

METHODS

PubMed and PsychINFO were searched for literature data about the acute and residual cognitive deficits following GHB use. This review is conducted using the PRISMA protocol.

RESULTS

A total of 43 reports covering human and animal data on GHB-induced cognitive impairments were eligible and reviewed. This systematic review found no indication for cognitive impairments after clinical GHB use. However, it supports the view that moderate GHB use may result in acute short-term cognitive impairments, whereas regular high-dose GHB use and/or multiple GHB-induced comas are probably neurotoxic resulting in long-term residual cognitive impairments.

CONCLUSION

These results emphasize the need for awareness among clinicians and recreational users to minimize negative health consequences of recreational GHB use, particularly when high doses are used and GHB-induced comas occur.

Association between anesthesia technique and complications after hip surgery in the elderly population

BACKGROUND

Spinal anesthesia is superior to general anesthesia for postoperative recovery in older patients (≥ 65 age). However, evidence for this is lacking.

AIM

To evaluate the effect of anesthesia on postoperative complications in older patients undergoing hip surgery.

METHODS

This is a retrospective, propensity score-matched, cohort study. Patients ≥ 65-years-old who underwent hip surgery at the Traditional Chinese Medicine of Guangdong Provincial Hospital in China from October 2016 to June 2020 were included. The operative methods were femoral fracture's internal fixation and hip replacement. The orthopedic doctors in different hospitals of our group have varied requirements for patients' out-of-bed time after surgery. Therefore, spinal anesthesia or general anesthesia was selected according to the requirements of the orthopedic doctors. The primary outcome of this study was complications during the hospitalization of the postoperative patient. The length of hospital stay, postoperative blood transfusion, routine blood analysis, renal function, coagulation function, and inflammatory correlations were secondary outcomes. Propensity score matching (PSM) was performed utilizing logistic regression.

RESULTS

Among the 864 patients identified from the electronic medical record data database, we screened out those with incomplete medical record data. After PSM of the baseline values of the two groups of patients, data of 309 patients (206 patients in spinal anesthesia group and 103 patients in general anesthesia) were utilized in this study. 67/309 patients had complications, including postoperative limb dysfunction, pulmonary infection, delirium, lower extremity venous thrombosis, and shock. The incidence of complications was not related to anesthesia methods (P > 0.05), but the levels of D-Dimer (P = 0.017), fibrinogen (P = 0.005), and high-sensitivity C-reactive protein (hsCRP) (P = 0.002) in the spinal anesthesia group were significantly higher than those in the general anesthesia group.

CONCLUSION

Anesthesia technology is not a risk factor for postoperative complications of hip surgery. The levels of D-Dimer and hsCRP were higher in the spinal anesthesia group.

Factors associated with post-operative delirium in hip fracture patients: what should we care

Background

The postoperative delirium is a common yet serious complication in elderly patients with hip fracture. We aimed to evaluate the potential risk factors of delirium in patients with hip fracture, to provide reliable evidence to the clinical management of hip fracture.

Methods

This study was a retrospective design. Elderly patients who underwent hip fracture surgery in our hospital from June 1, 2019 to December 30, 2020 were selected. The characteristics and treatment data of delirium and no delirium patients were collected and compared. Multivariate logistic regression analysis was performed to analyze the influencing factors affecting postoperative delirium in elderly patients with hip fracture.

Results

A total of 245 patients with hip fracture were included, the incidence of postoperative delirium in patients with hip fracture was 13.06%. There were significant differences in the age, BMI, history of delirium, estimated blood loss and duration of surgery (all p  < 0.05). There were significant differences in the albumin and TSH between delirium and no delirium group (all p < 0.05), Logistics analyses indicated that age ≥ 75 years (OR 3.112, 95% CI 1.527–5.742), BMI ≥ 24 kg/m² (OR 2.127, 95% CI 1.144–3.598), history of delirium (OR 1.754, 95% CI 1.173–2.347), estimated blood loss ≥ 400 mL (OR 1.698, 95% CI 1.427–1.946), duration of surgery ≥ 120 min (OR 2.138, 95% CI 1.126–3.085), preoperative albumin ≤ 40 g/L (OR 1.845, 95% CI 1.102–2.835) and TSH ≤ 2 mU/L (OR 2.226, 95% CI 1.329–4.011) were the independent risk factors of postoperative delirium in patients with hip fracture(all p < 0.05).

Conclusions

Postoperative delirium is very common in elderly patients with hip fracture, and it is associated with many risk factors, clinical preventions targeted on those risk factors are needed to reduce the postoperative delirium.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00660-9.

Regional anesthesia techniques and postoperative delirium: systematic review and meta-analysis

INTRODUCTION

Postoperative delirium is a frequent occurrence in the elderly surgical population. As a comprehensive list of predictive factors remains unknown, an opioid-sparing approach incorporating regional anesthesia techniques has been suggested to decrease its incidence. Due to the lack of conclusive evidence on the topic, we conducted a systematic review and meta-analysis to investigate the potential impact of regional anesthesia and analgesia on postoperative delirium.

EVIDENCE ACQUISITION

PubMed, Embase, and the Cochrane central register of Controlled trials (CENTRAL) databases were searched for randomized trials comparing regional anesthesia or analgesia to systemic treatments in patients having any type of surgery. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We pooled the results separately for each of these two applications by random effects modelling. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and strength of conclusions.

EVIDENCE SYNTHESIS

Eighteen trials (3361 subjects) were included. Using regional techniques for surgical anesthesia failed to reduce the risk of postoperative delirium, with a relative risk (RR) of 1.21 (95% CI: 0.79 to 1.85); P=0.3800. In contrast, regional analgesia reduced the relative risk of perioperative delirium by a RR of 0.53 (95% CI: 0.42 to 0.68; P<0.0001), when compared to systemic analgesia. Post-hoc subgroup analysis for hip fracture surgery yielded similar findings.

CONCLUSIONS

These results show that postoperative delirium may be decreased when regional techniques are used in the postoperative period as an analgesic strategy. Intraoperative regional anesthesia alone may not decrease postoperative delirium since there are other factors that may influence this outcome.

Monitored Anesthesia Care and Soft-Tissue Infiltration With Local Anesthesia for Short Cephalomedullary Nailing in Medically Complex Patients: A Technique Guide

Hip fractures are increasingly common and often occur in patients with complex medical comorbidities. There remains a need for a safer anesthetic option for these patients for the operative repair of their injury other than general or neuraxial anesthesia. At our institution, for medically complex and physiologically tenuous patients, we perform Monitored Anesthesia Care and Soft-Tissue Infiltration of Local Anesthetic (MAC-STILA) when performing percutaneous fixation techniques for hip fractures. We describe our technique here.

Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults

BACKGROUND

The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied.

METHODS

We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days.

RESULTS

A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30).

CONCLUSIONS

Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).

Safety of Different Anesthesia Methods Combined with Intravenous Fast Channel Anesthesia in Lower Extremity Orthopedic Surgery of the Elderly

Objective

To compare the safety of different anesthesia methods combined with intravenous fast channel anesthesia in elderly lower extremity surgery and the effect on postoperative outcome.

Methods

A total of 106 elderly patients who underwent lower extremity orthopedic surgery in our hospital from February 2018 to February 2021 were selected and randomly divided into the control group (n = 53) and the observation group (n = 53) according to random number table. All patients received intravenous fast-track anesthesia. On this basis, the control group received spinal-epidural anesthesia, and the observation group received iliac fascial space block on the affected side combined with sciatic nerve block. The operation conditions, blood pressure and heart rate changes, awakening time, postoperative ICU admission rate, and complications were compared between the two groups.

Results

There was no statistical difference in the success rate of one-time operation between the two groups (P > 0.05). The times of using analgesics and vasoactive drugs and the dosage of propofol in the observation group during the operation were lower than those in the control group, and the difference was statistically significant (P < 0.05). At T2, T3, and T4, the levels of HR, DBP, and SBP in the observation group were lower than those in the control group, and the difference was statistically significant (P < 0.05). After operation, the time of awakening, spontaneous breathing recovery, and extubation in the observation group were lower than those in the control group, and the difference were statistically significant (P < 0.05). The incidence of complications in the observation group was lower than that in the control group, the cognitive impairment was the most significant one in the incidence of single complication, and the difference was statistically significant (P < 0.05).

Conclusion

Based on the combined intravenous fast channel anesthesia, the operation difficulty of the affected side iliac fascial space block combined with sciatic nerve block is the same as that of spinal-epidural anesthesia. It has a higher success rate of one operation, better analgesic and anesthetic effects during the operation, and little effect on blood flow of patients. It can maintain relatively stable heart rate and blood pressure and does not easily cause postoperative complications. Its safety is higher than that of spinal-epidural anesthesia.

Relations of heart-type and brain-type fatty acid-binding proteins with postoperative cognitive dysfunction in elderly patients undergoing spinal surgery

OBJECTIVE

The aim of this study is to analyze the relations of heart-type fatty acid-binding protein (H-FABP) and brain-type fatty acid-binding protein (B-FABP) with postoperative cognitive dysfunction (POCD) in elderly patients undergoing spinal surgery.

METHODS

One hundred and twenty-five patients who underwent spinal surgery were enrolled in this study. According to whether patients had POCD within 5 days after surgery, the participants were divided into POCD group and non-POCD group. Before surgery and 6 h after surgery, the serum H-FABP and B-FABP contents were detected.

RESULTS

There were 33 (26.4%) patients in POCD group, and 92 (73.60%) patients in non-POCD group. After surgery, the serum H-FABP and B-FABP contents in POCD group were significantly higher than those before surgery, respectively (p<0.05), and those in non-POCD group were significantly lower than those before surgery, respectively (p<0.05). After surgery, the serum H-FABP and B-FABP contents in POCD group were significantly higher than those in non-POCD group, respectively (p<0.05).

CONCLUSION

The serum H-FABP and B-FABP contents are positively related to the occurrence of POCD in elderly patients undergoing spinal surgery.

Research status and prospect of peri-extubation delirium

Peri-extubation delirium is a clinical syndrome caused by multiple factors, and it is not a simple disease. It occurs within a period of time after extubation when the effect of general anesthesia is reduced. And the incidence is different in disparate populations, and it is more common in elderly patients. Current studies have shown that iatrogenic factors and patients' own factors are the main risk factors for the syndrome. Early identification of risk factors can help clinicians make early diagnosis. The earlier the diagnosis and treatment begin, the more significantly the prognosis of patients can be improved. At present, the treatment of perioperative delirium is based on non-drug therapy, supplemented by drug therapy. This review will introduce in detail the risk factors, population status and prevention measures of delirium during peri-extubation, and look forward to the new research direction in the future.

Immersive Virtual Reality Used as Adjunct Anesthesia for Conversion Total Hip Arthroplasty in a 100-Year-Old Patient

Immersive virtual reality (IVR) is an adjunctive form of anesthesia intended to distract patients from their intraoperative environment and reduce other side effects of sedating or narcotic agents. While this technology has been applied sparingly in various orthopedic procedural environments, its clinical utility has not been widely evaluated in major, nonelective surgical settings. The use of IVR in the geriatric hip fracture population represents a novel indication with potential benefit to reduced cognitive dysfunction and delirium. We report a case of a 100-year-old patient who received IVR adjunctive to neuraxial anesthesia during conversion total hip arthroplasty via posterolateral approach for treatment of failed peritrochanteric hip fracture fixation.

Effects of general versus subarachnoid anaesthesia on circadian melatonin rhythm and postoperative delirium in elderly patients undergoing hip fracture surgery: A prospective cohort clinical trial

BACKGROUND

Circadian rhythm disturbance is common postoperatively in older patients with hip fractures, which may contribute to the development of postoperative delirium (POD). As a reliable biomarker of endogenous circadian rhythms, melatonin regulates the sleep-wake cycle and environmental adaptation, and its secretory rhythm may be modified by anaesthesia and surgery. This study compared the impact of subarachnoid anaesthesia (SA) and general anaesthesia (GA), on the peak of melatonin secretion (primary outcome), the circadian rhythm of melatonin, cortisol and sleep, and the POD incidence (secondary outcome).

METHODS

In this prospective cohort observational study, hip fracture surgery patients were enrolled and assigned to receive either SA or GA. Postoperative plasma melatonin and cortisol levels were dynamically measured every six hours on seven time-points, and the circadian rhythm parameters including mesor, amplitude, and acrophase were calculated. Subjective and objective sleep assessments were performed by sleep diaries and sleep trackers, respectively. The Confusion Assessment Method was used twice daily by a specific geriatrician to screen for POD occurrence.

FINDINGS

In a cohort of 138 patients who underwent hip fracture surgery, the circadian rhythm disruption of the patients in the GA group (n=69) was greater than the SA group (n=69). Compared with SA, GA provided the lower peak concentration, mesor, and amplitude of melatonin secretion on postoperative day 1 (p < 0.05). Patients in the GA group experienced higher awakenings, more sleep deprivation, and poor sleep quality on surgery day (p < 0.05). A proportion of 12 patients in the SA group (17.4%) and 24 patients in the GA group (34.8%) experienced POD (p = 0.020).

INTERPRETATION

These results suggest that SA may be superior to GA in elderly patients undergoing hip fracture surgery as SA is associated with less impairment of the melatonin rhythm and sleep patterns, and fewer POD occurrences.

FUNDING

The study was supported by the National Natural Science Foundation of China (81971012, 81873726, 81901095, 81701052, and 81801070), Key Clinical Projects of Peking University Third Hospital (BYSYZD2019027), and Peking University "Clinical Medicine plus X" Youth Project (PKU2020LCXQ016).

Effect of General Versus Spinal Anesthesia on Postoperative Delirium and Early Cognitive Dysfunction in Elderly Patients

Background

Postoperative cognitive dysfunction (POCD) and delirium are common in the elderly patients, given the controversial results of previous studies about the impact of anesthesia type on the occurrence of these complications.

Objectives

This study was planned to compare the effects of general and spinal anesthesia on the prevalence of POCD and delirium.

Methods

A single-blind non-randomized clinical trial. Setting was in two academic hospitals. Ninety-four patients over 50 years old scheduled for hip fracture fixation. Patients were divided into two groups to receive either general (GA) or spinal (SA) anesthesia. Both Mini-Mental State examination (MMSE) and Wechsler tests were used before the operation and 3 times postoperatively to assess the cognitive function and detect early POCD. The DSM-IV criteria were also used for the diagnosis of delirium. The incidence of delirium and POCD and their precipitating factors were compared between the two groups.

Results

Ninety-four patients with a mean age of 67.12 years were studied. The overall prevalence of POCD and delirium was 17.02%; however, it was significantly higher in the GA group rather than the SA group, 29.7%, and 4.25%, respectively (P < 0.001). There was a significant relationship between age (P = 0.048), ASA class (P = 0.034), and educational level with the incidence of POCD, meaning that the probability of developing cognitive impairment decreases with patients' higher level of education and lower ASA-physical status. Also, the rate of POCD in men was significantly higher than in women (P = 0.026).

Conclusions

The finding of this study showed that, if there is no specific contraindication, neuraxial anesthesia may be preferred over general anesthesia in elderly patients.

Comparative efficacy of Neuraxial and general anesthesia for hip fracture surgery: a meta-analysis of randomized clinical trials

Background

The choice of anesthesia technique remains debatable in patients undergoing surgical repair of hip fracture. This meta-analysis was performed to compare the effect of neuraxial (epidural/spinal) versus general anesthesia on perioperative outcomes in patients undergoing hip fracture surgery.

Methods

Medline, Cochrane Library, Science-Direct, and EMBASE databases were searched to identify eligible studies focused on the comparison between neuraxial and general anesthesia in hip fracture patients between January 2000 and May 2019. Perioperative outcomes were extracted for systemic analysis. Sensitivity analyses were conducted using a Bonferroni correction and the leave-one-out method. The evidence quality for each outcome was evaluated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

Results

Nine randomized controlled trials (RCTs) including 1084 patients fulfilled our selection criteria. The outcomes for the meta-analysis showed that there were no significant differences in the 30-day mortality (OR = 1.34, 95% CI 0.56, 3.21; P = 0.51), length of stay (MD = − 0.65, 95% CI -0.32, 0.02; P = 0.06), and the prevalence of delirium (OR = 1.05, 95% CI 0.27, 4.00; P = 0.95), acute myocardial infarction (OR = 0.88, 95% CI 0.17, 4.65; P = 0.88), deep venous thrombosis (OR = 0.48, 95% CI 0.09, 2.72; P = 0.41), and pneumonia (OR = 1.04, 95% CI 0.23, 4.61; P = 0.96) for neuraxial anesthesia compared to general anesthesia, and there was a significant difference in blood loss between the two groups (MD = − 137.8, 95% CI -241.49, − 34.12; p = 0.009). However, after applying the Bonferroni correction for multiple testing, all the adjusted p-values were above the significant threshold of 0.05. The evidence quality for each outcome evaluated by the GRADE system was low.

Conclusions

In summary, our present study demonstrated that there might be a difference in blood loss between patients receiving neuraxial and general anaesthesia, however, this analysis was not robust to adjustment for multiple testing and therefore at high risk for a type I error. Due to small sample size and enormous inconsistency in the choice of outcome measures, more high-quality studies with large sample size are needed to clarify this issue.