Randomized comparison between sevoflurane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery

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.

Optimized Method of Unilateral Spinal Anesthesia: A Double-blind, Randomized Clinical Study

Background

Unilateral spinal anesthesia is often accompanied by technical difficulties in implementation, multiple puncture attempts, unsuccessful punctures, and, as a result, insufficient anesthesia, along with various complications associated with a dural puncture.

Objectives

This work compares the efficacy and safety of conventional Unilateral Spinal Anesthesia (USpA) and unilateral spinal anesthesia with electrical nerve stimulation (USpA+ENS).

Methods

A total of 134 patients with an upcoming vascular surgery on one lower extremity were randomly assigned to two groups. All the patients were positioned with the operated limb below and used 7.5 mg of Bupivacaine-Spinal®. In the UsPA group, anesthesia was performed according to the standard technique. In the USpA+ENS group, electrical nerve stimulation was additionally used. Primary outcomes were the presence or absence of post-dural puncture headache (PDPH), number of puncture attempts, lateralization, and anesthesia adequacy. Secondary outcomes were intraoperative pain scores, the presence or absence of nausea and vomiting, and the need for hemodynamics correction.

Results

The frequency of puncture complications was sufficiently lower in the USpA+ENS group than in the UsPA group. The local anesthetic solution distribution, pain score indicators, and secondary outcomes were comparable in both groups with a slight difference.

Conclusions

We showed that USpA+ENS reduces the incidence of puncture complications and improves the quality of anesthesia and adherence of both patients and anesthesiologists to the unilateral spinal anesthesia technique.

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.

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.

Perioperative outcomes in geriatric patients undergoing hip fracture surgery with different anesthesia techniques: A systematic review and meta-analysis

BACKGROUND

Previous meta-analyses assessing anesthetic techniques in adult patients undergoing hip fractures surgery are available. However, whether the anesthetic technique is associated with risk of mortality and complications in geriatric patients with hip fractures remains unclear. This study was conducted to assess postoperative outcomes of anesthesia technique in geriatric patients undergoing hip fracture surgery.

METHODS

Cochrane Library, PubMed, EMBASE, MEDLINE, CNKI, and CBM were searched from inception up to May 25, 2018. Observational studies and randomized controlled trials (RCTs) that assessed the perioperative outcomes of technique of anesthesia (general or regional [epidural/spinal/neuraxial]) in geriatric patients (≥60 years old) undergoing hip fracture surgery were included. Two investigators independently screened studies for inclusion and performed data extraction. Heterogeneity was assessed by the I and Chi-square tests. The odds ratio (OR) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CI) were calculated to assess the pooled data.

RESULTS

Eleven retrospective and 2 RCTs were included. There was no difference in 30-day mortality (OR = 0.96; 95% CI 0.86-1.08; P = .51) between the general and regional anesthesia groups. In-hospital mortality (OR = 1.26; 95% CI 1.17-1.36; P < .001), acute respiratory failure (OR = 2.66; 95% CI 2.34-3.02; P < .001), length of hospital stay (MD = 0.33; 95% CI 0.24-0.42; P < .001), and readmission (OR = 1.09; 95% CI 1.01-1.18; P = .03) were significantly reduced in the regional anesthesia group. Pneumonia (OR = 0.99; 95% CI 0.91-1.07; P = .79), heart failure (OR = 0.97; 95% CI 0.86-1.09; P = .62), acute myocardial infraction (OR = 1.07; 95% CI 0.99-1.16; P = .10), acute renal failure (OR = 1.32; 95% CI 0.97-1.79; P = .07), cerebrovascular accident (OR = 1.08; 95% CI 0.82-1.42; P = .58), postoperative delirium (OR = 1.51; 95% CI 0.16-13.97; P = .72), and deep vein thrombosis/pulmonary embolism (OR = 1.42; 95% CI 0.84-2.38; P = .19) were similar between the two anesthetic techniques.

CONCLUSION

General anesthesia is associated with increased risk of in-hospital mortality, acute respiratory failure, longer hospital stays, and higher readmission. There is evidence to suggest that regional anesthesia is associated with improved perioperative outcomes. Large RCTs are needed to explore the most optimal anesthetic techniques for geriatric patients with hip fractures before drawing final conclusions.

PROSPERO REGISTRATION NUMBER

CRD42018093582.

Effect of regional versus general anaesthesia on postoperative delirium in elderly patients undergoing surgery for hip fracture: a systematic review

OBJECTIVE

Older patients with hip fractures who are undergoing surgery are at high risk of significant mortality and morbidity including postoperative delirium. It is unclear whether different types of anaesthesia may reduce the incidence of postoperative delirium. This systematic review will investigate the impact of anaesthetic technique on postoperative delirium. Other outcomes included mortality, length of stay, complications and functional outcomes.

DESIGN

Systematic review of randomised controlled trials and non-randomised controlled studies.

DATA SOURCES

Bibliographic databases were searched from inception to June 2018. Web of Science and ZETOC databases were searched for conference proceedings. Reference lists of relevant articles were checked, and clinical trial registers were searched to identify ongoing trials.

ELIGIBILITY CRITERIA

Studies were eligible if general and regional anaesthesia were compared in patients (aged 60 and over) undergoing hip fracture surgery, reporting primary outcome of postoperative delirium and secondary outcomes of mortality, length of hospital stay, adverse events, functional outcomes, discharge location and quality of life. Exclusion criteria were anaesthetic technique or drug not considered current standard practice; patients undergoing hip fracture surgery alongside other surgery and uncontrolled studies.

RESULTS

One hundred and four studies were included. There was no evidence to suggest that anaesthesia type influences postoperative delirium or mortality. Some studies suggested a small reduction in length of hospital stay with regional anaesthesia. There was some evidence to suggest that respiratory complications and intraoperative hypotension were more common with general anaesthesia. Heterogeneity precluded meta-analysis. All findings were described narratively and data were presented where possible in forest plots for illustrative purposes.

CONCLUSIONS

While there was no evidence to suggest that anaesthesia types influence postoperative delirium, the evidence base is lacking. There is a need to ascertain the impact of type of anaesthesia on outcomes with an adequately powered, methodologically rigorous study.

PROSPERO REGISTRATION NUMBER

CRD42015020166.

Hypobaric Unilateral Spinal Anaesthesia versus General Anaesthesia in Elderly Patients Undergoing Hip Fracture Surgical Repair: A Prospective Randomised Open Trial

Objective

Intraoperative hypotension during hip fracture surgery is frequent in the elderly. No study has compared the haemodynamic effect of hypobaric unilateral spinal anaesthesia (HUSA) and standardised general anaesthesia (GA) in elderly patients undergoing hip fracture surgical repair.

Methods

We performed a prospective, randomised open study, including 40 patients aged over 75 years, comparing the haemodynamic effects of HUSA (5 mg isobaric bupivacaine with 5 μg sufentanil and 1 mL sterile water) and GA (induction with etomidate/remifentanil and maintenance with desflurane/remifentanil). An incidence of severe hypotension, defined by a decrease in systolic blood pressure of >40% from baseline, was the primary endpoint.

Results

The incidence of severe hypotension was lower in the HUSA group compared with that in the GA group (32% vs. 71%, respectively, p=0.03). The median [IQR] ephedrine consumption was lower (p=0.001) in the HUSA group (6 mg, 0-17 mg) compared with that in the GA group (36 mg, 21-57 mg). Intraoperative muscle relaxation and patients' and surgeons' satisfaction were similar between groups. No difference was observed in 5-day complications or 30-day mortality.

Conclusion

This study shows that HUSA provides better haemodynamic stability than GA, with lower consumption of ephedrine and similar operating conditions. This new approach of spinal anaesthesia seems to be safe and effective in elderly patients undergoing hip fracture surgery.

Comparison of the Effects of Dexmedetomidine and Remifentanil on Cognition State After Cataract Surgery

BACKGROUND

Dexmedetomidine is a potent and highly specific α2-adrenoreceptor agonist that induces sedative and analgesic effects over a short-term period. As a result of these benefits, dexmedetomidine may be a better alternative than other available drugs for keeping the patient's cognition state in an acceptable condition after outpatient ophthalmic surgeries.

OBJECTIVES

This randomized study was conducted to compare the sedative effects of dexmedetomidine and remifentanil on the cognitive state of patients who have undergone cataract surgery.

PATIENTS AND METHODS

A total of 100 patients who were candidates for cataract surgery under local anesthesia received either dexmedetomidine (50 patients; D group) or remifentanil (50 patients; R group) in a double-blind, randomized study. The baseline cardiovascular status and mini mental state examination (MMSE) score for each patient were recorded. As a loading dose, dexmedetomidine (0.5 µg/kg) and remifentanil (0.1 µg/kg) were infused at 10 minutes and 5 minutes before topical anesthesia, respectively. Subsequently, the maintenance dose was administered at 0.2 µg/kg/hour and 0.05 µg/kg/minutes in the D and R groups, respectively. The surgical procedure was begun when the bispectral index (BIS) reached 70 - 80. MMSE test was done at a postanesthetic care unit (PACU) 120 minutes after the discontinuation of the drug.

RESULTS

There was no statistically significant difference between the MMSE scores of the two groups before surgery (P = 0.6), but the MMSE test conducted at the PACU revealed significantly better cognitive outcomes in the D group than in the R group in patients younger and older than 65 years (P = 0.03 and P = 0.0001, respectively).

CONCLUSIONS

This study revealed that dexmedetomidine may be a suitable agent for sedation in cataract surgery because it results in a more favorable postoperative cognitive status than remifentanil. Likewise, dexmedetomidine had no significant adverse effects on cardiovascular or respiratory systems.

Anaesthesia for hip fracture surgery in adults

BACKGROUND

The majority of people with hip fracture are treated surgically, requiring anaesthesia.

OBJECTIVES

The main focus of this review is the comparison of regional versus general anaesthesia for hip (proximal femoral) fracture repair in adults. We did not consider supplementary regional blocks in this review as they have been studied in another review.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library; 2014, Issue 3), MEDLINE (Ovid SP, 2003 to March 2014) and EMBASE (Ovid SP, 2003 to March 2014).

SELECTION CRITERIA

We included randomized trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The main outcomes were mortality, pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, deep vein thrombosis and return of patient to their own home.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. We analysed data with fixed-effect (I(2) < 25%) or random-effects models. We assessed the quality of the evidence according to the criteria developed by the GRADE working group.

MAIN RESULTS

In total, we included 31 studies (with 3231 participants) in our review. Of those 31 studies, 28 (2976 participants) provided data for the meta-analyses. For the 28 studies, 24 were used for the comparison of neuraxial block versus general anaesthesia. Based on 11 studies that included 2152 participants, we did not find a difference between the two anaesthetic techniques for mortality at one month: risk ratio (RR) 0.78, 95% confidence interval (CI) 0.57 to 1.06; I(2) = 24% (fixed-effect model). Based on six studies that included 761 participants, we did not find a difference in the risk of pneumonia: RR 0.77, 95% CI 0.45 to 1.31; I(2) = 0%. Based on four studies that included 559 participants, we did not find a difference in the risk of myocardial infarction: RR 0.89, 95% CI 0.22 to 3.65; I(2) = 0%. Based on six studies that included 729 participants, we did not find a difference in the risk of cerebrovascular accident: RR 1.48, 95% CI 0.46 to 4.83; I(2) = 0%. Based on six studies that included 624 participants, we did not find a difference in the risk of acute confusional state: RR 0.85, 95% CI 0.51 to 1.40; I(2) = 49%. Based on laboratory tests, the risk of deep vein thrombosis was decreased when no specific precautions or just early mobilization was used: RR 0.57, 95% CI 0.41 to 0.78; I(2) = 0%; (number needed to treat for an additional beneficial outcome (NNTB) = 3, 95% CI 2 to 7, based on a basal risk of 76%) but not when low molecular weight heparin was administered: RR 0.98, 95% CI 0.52 to 1.84; I(2) for heterogeneity between the two subgroups = 58%. For neuraxial blocks compared to general anaesthesia, we rated the quality of evidence as very low for mortality (at 0 to 30 days), pneumonia, myocardial infarction, cerebrovascular accident, acute confusional state, decreased rate of deep venous thrombosis in the absence of potent thromboprophylaxis, and return of patient to their own home. The number of studies comparing other anaesthetic techniques was limited.

AUTHORS' CONCLUSIONS

We did not find a difference between the two techniques, except for deep venous thrombosis in the absence of potent thromboprophylaxis. The studies included a wide variety of clinical practices. The number of participants included in the review is insufficient to eliminate a difference between the two techniques in the majority of outcomes studied. Therefore, large randomized trials reflecting actual clinical practice are required before drawing final conclusions.

Optimal perioperative management of arterial blood pressure

Perioperative blood pressure management is a key factor of patient care for anesthetists, as perioperative hemodynamic instability is associated with cardiovascular complications. Hypertension is an independent predictive factor of cardiac adverse events in noncardiac surgery. Intraoperative hypotension is one of the most encountered factors associated with death related to anesthesia. In the preoperative setting, the majority of antihypertensive medications should be continued until surgery. Only renin-angiotensin system antagonists may be stopped. Hypertension, especially in the case of mild to moderate hypertension, is not a cause for delaying surgery. During the intraoperative period, anesthesia leads to hypotension. Hypotension episodes should be promptly treated by intravenous vasopressors, and according to their etiology. In the postoperative setting, hypertension predominates. Continuation of antihypertensive medications and postoperative care may be insufficient. In these cases, intravenous antihypertensive treatments are used to control blood pressure elevation.

Post-operative cognitive dysfunction in the elderly: A prospective clinical study

Background and Aims:

Aging population is a major demographic trend worldwide. Globally, 50% of all the elderly individuals are estimated to undergo atleast one surgical procedure and post-operative cognitive dysfunction (POCD) is one of the most common and often poorly understood post-operative complications in this section of the population. This randomised prospective study was conducted to assess the post-operative cognitive status in the elderly undergoing non-cardiac surgery, evaluate the cognitive parameters affected, evaluate the potential risk factors and thereby analyse the potential for implementation of preventive strategies.

Methods:

This study was conducted on 200 patients aged 60 years or older scheduled for elective non-cardiac surgeries. The baseline cognitive status of the patients was assessed 2 days prior to the date of the surgery. The post-operative cognitive status was assessed on the 3^rd day, 7^th day and after 1 month. Statistical analysis was performed using SAS and SPSS.

Results:

The incidence of POCD showed a gradual decline from postoperative day 3 to 30. Females were found to be at significant risk in developing POCD. Advancing age and level of education emerged as dominant factors, while type of anaesthesia, duration of surgery, and presence of coexisting comorbidities had no influence on the incidence of cognitive dysfunction.

Conclusion:

POCD is a definite complication after surgery and anaesthesia in the elderly population. Gender emerged as a significant risk factor with increasing age as a dominating factor contributing to POCD.

Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews

BACKGROUND

Various beneficial effects derived from neuraxial blocks have been reported. However, it is unclear whether these effects have an influence on perioperative mortality and major pulmonary/cardiovascular complications.

OBJECTIVES

Our primary objective was to summarize Cochrane systematic reviews that assess the effects of neuraxial blockade on perioperative rates of death, chest infection and myocardial infarction by integrating the evidence from all such reviews that have compared neuraxial blockade with or without general anaesthesia versus general anaesthesia alone for different types of surgery in various populations. Our secondary objective was to summarize the evidence on adverse effects (an adverse event for which a causal relation between the intervention and the event is at least a reasonable possibility) of neuraxial blockade. Within the reviews, studies were selected using the same criteria.

METHODS

A search was performed in the Cochrane Database of Systematic Reviews on July 13, 2012. We have (1) included all Cochrane systematic reviews that examined participants of any age undergoing any type of surgical (open or endoscopic) procedure, (2) compared neuraxial blockade versus general anaesthesia alone for surgical anaesthesia or neuraxial blockade plus general anaesthesia versus general anaesthesia alone for surgical anaesthesia and (3) included death, chest infection, myocardial infarction and/or serious adverse events as outcomes. Neuraxial blockade could consist of epidural, caudal, spinal or combined spinal-epidural techniques administered as a bolus or by continuous infusion. Studies included in these reviews were selected on the basis of the same criteria. Reviews and studies were selected independently by two review authors, who independently performed data extraction when data differed from one of the selected reviews. Data were analysed by using Review Manager Version 5.1 and Comprehensive Meta Analysis Version 2.2.044.

MAIN RESULTS

Nine Cochrane reviews were selected for this overview. Their scores on the Overview Quality Assessment Questionnaire varied from four to six of a maximal possible score of seven. Compared with general anaesthesia, neuraxial blockade reduced the zero to 30-day mortality (risk ratio [RR] 0.71, 95% confidence interval [CI] 0.53 to 0.94; I(2) = 0%) based on 20 studies that included 3006 participants. Neuraxial blockade also decreased the risk of pneumonia (RR 0.45, 95% CI 0.26 to 0.79; I(2) = 0%) based on five studies that included 400 participants. No difference was detected in the risk of myocardial infarction between the two techniques (RR 1.17, 95% CI 0.57 to 2.37; I(2) = 0%) based on six studies with 849 participants. Compared with general anaesthesia alone, the addition of a neuraxial block to general anaesthesia did not affect the zero to 30-day mortality (RR 1.07, 95% CI 0.76 to 1.51; I(2) = 0%) based on 18 studies with 3228 participants. No difference was detected in the risk of myocardial infarction between combined neuraxial blockade-general anaesthesia and general anaesthesia alone (RR 0.69, 95% CI 0.44 to 1.09; I(2) = 0%) based on eight studies that included 1580 participants. The addition of a neuraxial block to general anaesthesia reduced the risk of pneumonia (RR 0.69, 95% CI 0.49 to 0.98; I(2) = 9%) after adjustment for publication bias and based on nine studies that included 2433 participants. The quality of the evidence was judged as moderate for all six comparisons.No serious adverse events (seizure or cardiac arrest related to local anaesthetic toxicity, prolonged central or peripheral neurological injury lasting longer than one month or infection secondary to neuraxial blockade) were reported. The quality of the reporting score of complications related to neuraxial blocks was nine (four to 12 (median range)) of a possible maximum score of 14.

AUTHORS' CONCLUSIONS

Compared with general anaesthesia, a central neuraxial block may reduce the zero to 30-day mortality for patients undergoing surgery with intermediate to high cardiac risk (level of evidence, moderate). Further research is required.

Cerebral oximetry and cognitive dysfunction in elderly patients undergoing surgery for hip fractures: a prospective observational study

Aim:

This study was conducted to examine perioperative cerebral oximetry changes in elderly patients undergoing hip fracture repair and evaluate the correlation between regional oxygen saturation (rSO₂) values, postoperative cognitive dysfunction (POCD) and hospital stay.

Materials and Methods:

This prospective observational study included 69 patients. Data recorded included demographic information, rSO₂ values from baseline until the second postoperative hour and Mini Mental State Examination (MMSE) scores preoperatively and on postoperative day 7. MMSE score ≤23 was considered evidence of cognitive dysfunction. Postoperative confusion or agitation, medications administered for postoperative agitation, and hospital length of stay were also recorded. Data were analyzed with Student’s t-test, Pearson’s correlation or multiple regression analysis as appropriate.

Results:

Patient age was 74±13 years. Baseline left sided rSO₂ values were 60±10 and increased significantly after intubation. Baseline rSO₂ L<50 and <45 was observed in 11.6% and 10.1% of patients respectively. Perioperative cerebral desaturation occurred in 40% of patients. MMSE score was 26.23 ± 2.77 before surgery and 25.94 ± 2.52 on postoperative day 7 (p=0.326). MMSE scores ≤ 23 were observed preoperatively in 6 and postoperatively in 9 patients. Patients with cognitive dysfunction had lower preoperative hematocrit, hemoglobin, SpO₂ and rSO₂ values at all times, compared to patients who did not. There was no correlation between rSO₂ or POCD and hospital stay. Patients with baseline rSO₂ <5 required more medications for postoperative agitation.

Conclusion:

Cognitive dysfunction occurs preoperatively and postoperatively in elderly patients with hip fractures, and is associated with low cerebral rSO₂ values.

General anaesthesia does not contribute to long-term post-operative cognitive dysfunction in adults: A meta-analysis

CONTEXT

The contribution of anaesthesia itself to post-operative cognitive dysfunction (POCD) or the potential protective effect of one specific type of anaesthesia on the occurrence of POCD is unclear.

AIMS

This is a meta-analysis evaluating the effects of the anaesthetic technique (regional vs. general anaesthesia) on POCD of patients undergoing non-cardiac surgery.

SETTINGS AND DESIGN

Meta-analysis performed in a University affiliated hospital.

METHODS

A search for randomized controlled trials (RCT) comparing regional anaesthesia to general anaesthesia for surgery was done in PUBMED, MEDLINE, EMBASE, EBM Reviews-Cochrane Central Register of Controlled Trials, PsychINFO and Current Contents/all editions in 2009.

STATISTICAL ANALYSIS

Data were analyzed with comprehensive Meta-analysis Version 2.2.044.

RESULTS

Twenty-six RCTs including 2365 patients: 1169 for regional anaesthesia and 1196 for general anaesthesia were retained. The standardized difference in means for the tests included in the 26 RCTs was -0.08 (95% confidence interval: -0.17-0.01; P value 0.094; I-squared = 0.00%). The assessor was blinded to the anaesthetic technique for 12 of the RCTs including only 798 patients: 393 for regional anaesthesia and 405 for general anaesthesia. The standardized difference in means for these 12 studies is 0.05 (-0.10-0.20; P=0.51; I-squared = 0.00%).

CONCLUSIONS

The present meta-analysis does not support the concerns that a single exposure to general anaesthesia in an adult would significantly contribute to permanent POCD after non-cardiac surgery.

Neuroaxial versus general anaesthesia in geriatric patients for hip fracture surgery: does it matter?

The influence of the mode of anaesthesia on outcome of geriatric patients with hip fractures is a controversial issue in the medical literature. In the light of an ageing society, a conclusive answer to this question is of growing importance. The purpose of this review was to assess the effect of neuroaxial and general anaesthesia on mortality and morbidity in geriatric patients sustaining a hip fracture. Following a current literature search within the Pubmed and Cochrane database (1967-2010), 34 randomised controlled trials, 14 observational studies and eight reviews/meta-analysis publications were included. Potentially outcome-influencing factors such as mortality, deep vein thrombosis, pulmonary embolism, postoperative confusion and other anaesthesia-related outcomes were evaluated. After analysing the current literature with 56 references, covering 18,715 patients with hip fracture, it can be concluded that spinal anaesthesia is associated with significantly reduced early mortality, fewer incidents of deep vein thrombosis, less acute postoperative confusion, a tendency to fewer myocardial infarctions, fewer cases of pneumonia, fatal pulmonary embolism and postoperative hypoxia. General anaesthesia has the advantages of having a lower incidence of hypotension and a tendency towards fewer cerebrovascular accidents compared to neuroaxial anaesthesia. Otherwise, general anaesthesia and respiratory diseases were significant predictors of morbidity in hip fracture patients. These data suggest that regional anaesthesia is the preferred technique, but the limited evidence available does not permit a definitive conclusion to be drawn for mortality or other outcomes. For hip fracture surgery, the choice of anaesthesia (general or neuroaxial) is made by the anaesthesiologist and is based on the patient's preference, comorbidities, potential general postoperative complications and the clinical experience of the anaesthesiologist. The overall therapeutic approach in hip fracture care should be determined jointly by the orthopaedic surgeon, the geriatrician and the anaesthesiologist (multidisciplinary approach).

Monitoring cerebral oxygen saturation in elderly patients undergoing general abdominal surgery: a prospective cohort study

BACKGROUND AND OBJECTIVES

The aim of this prospective, observational study was to evaluate changes in regional cerebral oxygen saturation (rSO2) and incidence of intraoperative cerebral desaturation in a cohort of elderly patients undergoing major abdominal surgery.

METHODS

rSO2 was continuously monitored on the left and right sides of the forehead in 60 patients older than 65 yr (35 males and 25 females; ASA II-III; age: 72 +/- 5 yr; without pre-existing cerebral pathology, and baseline Mini Mental State Examination (MMSE) score >23) undergoing sevoflurane anaesthesia for major abdominal, non-vascular surgery >2 h.

RESULTS

Baseline rSO2 was 63 +/- 8%; cerebral desaturation (rSO2 decrease <75% of baseline or <80% in case of baseline rSO2 <50%) occurred in 16 patients (26%). The MMSE decreased from 28 +/- 1 before surgery to 27 +/- 2 on 7th postoperative day (P = 0.05). A decline in cognitive function (decrease in MMSE score > or = 2 points one week after surgery as compared to baseline value) was observed in six patients without intraoperative cerebral desaturation (13.6%) and six patients who had intraoperative cerebral desaturation (40%) (P = 0.057) (odds ratio: 4.22; CI95%: 1.1-16). Median (range) hospital stay was 14 (5-41) days in patients with an area under the curve of rSO2 <50% (AUCrSO2<50%) >10 min%, and 10 (4-30) days in those with an AUCrSO2<50% <10 min% (P = 0.0005).

CONCLUSIONS

In a population of healthy elderly patients, undergoing non-vascular abdominal surgery cerebral desaturation can occur in up to one in every four patients, and the occurrence of cerebral desaturation is associated with a higher incidence of early postoperative cognitive decline and longer hospital stay.