Isolated outpatient ossiculoplasty under potentialized local anesthesia and general anesthesia: Comparative STROBE analysis of early results.

Inguinal herniorrhaphy is one of the most frequent operations and can be successfully performed using general, regional, or local anesthesia. Epidemiological data from both nationwide (1) and large regional (2,3) databases have found that general anesthesia is used in 60%–70% of cases, central neuraxis blockade in 10%–20%, and local infiltration anesthesia in only 5%– 15% of cases. Even though local anesthesia with sedation (so-called monitored anesthesia care) is a more cost-effective anesthetic technique for inguinal hernia repair (4), general and spinal anesthesia remain the most popular anesthetic techniques at universitybased teaching programs. Interestingly, specialized hernia centers use local infiltration anesthesia in more than 95% of these cases (5– 8).

P140. Cost effectiveness analysis of spinal anesthesia versus general anesthesia in lumbar fusion surgery

The aging of the baby-boom population and the decreases in adult mortality seen in the last few decades will dramatically increase the age of Americans between 2010 and 2030. During that time, the population older than age 65 yr is expected to grow by 75%, whereas between 1995 and 2050, the cumulative growth of the population older than 85 yr is expected to exceed 400% (1). Furthermore, it has been reported that the increased demand for surgery in this population may exceed the rate of population growth (2). The implications of an aging population for the practice of anesthesiology are profound. Age-related changes in physiology and pharmacology can affect every aspect of perioperative care. The changes in surgical demographics will compel the anesthesiologist to become familiar with the physiology and clinical care of the aged. This review will serve as an introduction. First, some of the physiologic changes that occur with aging will be presented. Second, the preoperative assessment of the older surgical patient will be discussed. Third, some of the research related to intraoperative management of the geriatric surgical patient will be described. In the fourth section, we will discuss some geriatric-specific issues related to postoperative management. Physiologic Changes Relevant to Perioperative Care The most important generalization from physiologic studies of aging is that the basal function of the various organ systems is relatively uncompromised by the aging process per se. However, functional reserve and the ability to compensate for physiologic stress are reduced (Fig. 1).Figure 1: Schematic representation of the relationship between maximal (broken line) and basal (solid line) physiologic function. Functional reserve is the difference between maximal and basal function. Aging inevitably reduces functional reserve even in individuals who are physiologically "young." The configuration of the curve for basal function is adapted from longitudinal measurements of total (not weight-specific) basal metabolic rate. Reprinted with permission: Muravchick S. Geroanesthesia: principles for management of the elderly patient. St. Louis: Mosby, 1996 (Figures 1–3).Cardiovascular Changes Cardiovascular changes with aging have implications for anesthetic care. Changes in the vascular system and hemodynamics can affect every organ bed. The Framingham Heart Study documented a nearly linear increase in systolic blood pressure from age 30 to 84 yr (3). Age-related hypertension is attributable to a 50%–75% increase in arterial stiffness and a 25% increase in systemic vascular resistance (3,4). Increased sympathetic nervous system activity and decreased peripheral β-adrenergic responsiveness further contribute to the hypertension of aging (5). Ventricular hypertrophy develops in response to increased afterload, increasing wall stress, myocardial oxygen demand, and increasing susceptibility to ischemia. Although intrinsic contractility and resting cardiac output are unaltered with aging, ventricular hypertrophy and stiffening limit the ability of the heart to adjust stroke volume (6) and impair passive ventricular filling. In the elderly, changes in ventricular end-diastolic volume in response to either positive or negative changes in central venous pressure are typically half those seen in young or middle-aged subjects (7). At the same time, fatty infiltration and fibrosis of the heart increases the incidence of sinus, atrioventricular, and ventricular conduction defects (8). With aging there is also decreased myocardial responsiveness to catecholamines and a diminished heart rate response (6). These processes compromise the heart's ability to buffer changes in circulatory volume, resulting in a disposition to either congestive heart failure or hypotension. From the standpoint of perioperative hemodynamic stability, age-related changes in the autonomic control of heart rate, cardiac output, peripheral vascular resistance, and the baroreceptor response (7,9,10) are as important as the changes in the myocardium and vasculature. Age-related changes in the cardiovascular system involve alterations in both mechanics and control mechanisms; the same can be said of the pulmonary system. Pulmonary System Age-related changes in the pulmonary system parallel changes in the heart. With time, the thorax becomes stiffer, increasing the work of breathing and reducing maximal minute ventilation (11,12). Loss of thoracic skeletal muscle mass aggravates this process. Residual volume and functional residual capacity (FRC) both increase with age—5%–10% and 1%–3% per decade, respectively—whereas the forced expiratory volume in 1 s is reduced approximately 6% to 8% per decade (Fig. 2) (11,13). Because of reduced elastic recoil, the closing volume increases such that it exceeds FRC by age 65 (14). In the supine position, closing capacity may reach FRC by 44 yr of age (11). Inspiratory and expiratory functional reserve decrease with aging, and the normal matching of ventilation and perfusion decreases (15). The respiratory response to hypoxia also diminishes with aging (16); there is a decrease in ciliary function, and cough is reduced (11). Finally, pharyngeal sensation and the motor function required for swallowing are diminished in the elderly (17,18).Figure 2: Mean forced expiratory volume in 1 s (FEV1) versus age for men of differing ethnic groups. Reprinted with permission: Am J Respir Crit Care Med 1999;159:179–87 (Figure 1).Neurologic Changes with Aging Cardiopulmonary complications account for most morbidity and mortality in older surgical patients; however, neurologic morbidity affects a large number of patients, and age-related degenerative changes in the central and peripheral nervous systems contribute to a variety of other morbidities. Both the central and peripheral nervous systems are affected by aging (19). There is a decrease in cortical gray matter through middle age, resulting in cerebral atrophy (20). The ratio of gray to white matter decreases from 1.28 at 20 yr to a low of 1.13 at 50 yr, followed by an increase of this ratio to 1.55 at 100 yr of age. The latter increase appears to reflect a disproportionate loss of white matter in the latest decades (20). For the cortical gray matter, a decrease in neuronal volume appears more important than neuronal loss (21,22). There is also a reduction in the complexity of neuronal connections, a decrease in the synthesis of neurotransmitters, and an increase in the enzymes responsible for their postsynaptic degradation (20). Although cerebral metabolism, blood flow, and autoregulation generally remain intact (20), dendritic regression and the deficiency of neurotransmitters limit the ability of the older brain to integrate multiple neural inputs. Neuronal loss and demyelinization also occur in the spinal cord (23). Functionally, there are changes in spinal cord reflexes and reductions in proprioception. There are also important decreases in hypoxic and hypercarbic drive (11,24). Declines in visual and auditory function further complicate the ability of the nervous system to acquire and process information. This combination of changes can limit the ability of the older patient to understand and process information in the perioperative period. These changes are probably important contributors to postoperative delirium, drug toxicity, and falls. Aging is also associated with neuronal loss in the autonomic nervous system. Sympathetic and parasympathetic ganglia lose neurons, and there is fibrosis of peripheral sympathetic neurons. This peripheral neuronal adrenergic loss is associated with impairment of cardiovascular reflexes. At the same time, decreases in adrenoceptor responsiveness result in increased adrenomedullary output and plasma catecholamine concentrations (9,10,23). Circulating norepinephrine levels have been reported to increase approximately 60% (230 to 380 pg/mL) between age 20 and age 70 (10). Skeletal muscle innervation decreases, translating into a loss of motor units and a decrease in strength, coordination, and fine motor control (25). Joint position and vibration sense may be compromised, and the literature suggests some diminution in the processing of painful stimuli (26,27). However, this effect, if it exists, appears to be modest at best and does not affect all nerve types equally (27–29). Furthermore, given huge interpatient variability in nervous system function and in the experience of pain, alterations in subtypes of pain perception do not translate into a decreased need for analgesia in the elderly (29–32). Renal Aging is accompanied by a progressive decrease in renal blood flow (approximately 10% per decade after age 50) and loss of renal parenchyma (33). Furthermore, by the eighth decade, 10%–30% of remaining nephrons are sclerotic, reducing the functional capacity of the reduced nephronal number (34). Together these processes result in a progressive decrease in glomerular capillary surface area and glomerular filtration rate. However, because of loss of muscle mass, aging is not associated with an increase in serum creatinine. This physiologic, and often occult, aspect of senescence has practical implications in the perioperative period. The old kidney has difficulty in maintaining circulating blood volume and sodium homeostasis perioperatively (9,35). Fluid homeostasis is further complicated by alterations in thirst mechanisms and antidiuretic hormone release that frequently result in dehydration (35). Perioperatively, metabolic acidosis is also relatively common in elderly patients who are less efficient in the renal excretion of acid. Reductions in basal renal blood flow and a diminished response to vasodilatory stimuli (33,36) render the elderly kidney particularly susceptible to the deleterious effects of low cardiac output, hypotension, hypovolemia, and hemorrhage. Anesthetics, surgical stress, pain, sympathetic stimulation, and renal vasoconstrictive drugs may all compound subclinical renal insufficiency. Aging: Pharmacokinetics and Pharmacodynamics Our knowledge of the pharmacology of aging is limited by the fact that elderly patients are often systematically excluded from drug trials (37). This is a travesty because elderly patients are the largest users of prescription drugs. That said, certain predictions can be made about pharmacology in the elderly. With aging there is decreased lean body mass and total body water and an increased proportion of body fat; these alter the volume of distribution and redistribution of drugs and alter their rates of clearance and elimination. In a study of population pharmacokinetics for propofol, elimination clearance of the anesthetic was found to decrease linearly with age >60 yr, even correcting for changes in body weight (38). Furthermore, even though age-related changes in plasma proteins make generalizations about the pharmacokinetics complex, decreased protein binding and increased free fraction have the potential to increase the pharmacologic effect of drugs used perioperatively (39). Furthermore, alterations in cardiac output and renal or hepatic clearance may change drug plasma concentrations and their duration of action (40). Neuronal loss and decreased levels of neurotransmitters may increase sensitivity to anesthetics. The changes in pharmacokinetics that occur with aging make it difficult to identify an independent effect of aging on pharmacodynamics (41). However, age-related changes in the central nervous system appear to increase the sensitivity to a variety of anesthetics (42,43). This is probably best described for propofol, where elderly patients are approximately 30%–50% more sensitive than younger patients (44); this sensitivity is independent of the decreased clearance of the drug. Pharmacokinetic and pharmacodynamic changes, together with drug interactions and polypharmacy, conspire to make the elderly prone to adverse drug effects. There is an almost linear increase in adverse drug reactions with age (45,46), and the likelihood of adverse drug reactions increases with the number of drugs administered. The addition of several drugs, even short-acting ones, in the perioperative period makes adverse reactions likely. Implications What is clear from a review of the physiologic changes with aging is that even the fit elderly patient's ability to compensate for perioperative stress is compromised. The cardiac, pulmonary, neurologic, and neuroendocrine changes that occur with aging make hypotension, low cardiac output, hypoxia, hypercarbia, and disordered fluid regulation more commonplace in the perioperative period. Furthermore, because baseline cardiac, pulmonary, renal, and neurologic function is typically adequate in the absence of acute challenges, it can be very difficult to predict the effect of perioperative stress on the older patient. Preoperative Assessment of the Elderly Historically, preoperative assessment has served to alert the surgical care providers to physiologic conditions that may alter perioperative management and to determine whether medical intervention is indicated before proceeding. Two more contemporary uses of the preoperative assessment are to provide an index of risk and therefore contribute to decisions about the most appropriate intervention and to provide baseline data on which the success of a surgical intervention might be judged. Despite physiologic changes with aging and multiple comorbidities, even extreme age is not a contraindication to surgery (47–49). What is less clear is how to identify which patients will do well and which will do poorly. No area of perioperative anesthetic care and management requires more investigation. The preoperative assessment of the patient is composed of four interrelated functions: risk stratification, as defined by population-based studies; history and physical examination, including functional assessment of the individual patient; preoperative testing; and, in some cases, preoperative optimization. Population Studies. Because age itself adds little additional risk in the absence of comorbid disease (50), most risk factor identification and risk predictive indices have been disease oriented (51–55). These investigations have typically studied a broad age range of patients and in multivariate analyses identified the relative contribution of age, ASA status, specific surgical factors, intraoperative management, and comorbid conditions to surgical morbidity and mortality (52,53,56–60). The applicability of many existing risk indices to the geriatric population is unclear. Because of the prevalence of comorbid conditions, it is difficult to stratify the older patient population into smaller subsets with better-defined risk. The scarcity of population studies of perioperative risk and outcomes specifically in geriatric populations can make it difficult to provide good information or to choose the most suitable course of care. Furthermore, elderly patients have relatively unique risks. In addition to death, myocardial infarction, or congestive heart failure, older patients are unusually prone to postoperative delirium, aspiration, urosepsis, adverse drug reactions, malnutrition, falls, and failure to return to ambulation or to home. Therefore, preoperative assessment tools and the variables evaluated in outcomes trials require expansion for application to the geriatric surgical population. Once completed, epidemiologic studies that better stratify older patients would help to define the appropriate preoperative assessment. Functional Assessments. Functional evaluation of elderly surgical patients requires greater attention. This is important for several reasons. First, the evaluation of the "resting" patient does not indicate how the patient will respond to perioperative physiologic demands. Second, because of patient heterogeneity, functional assessments may be indicated to better characterize patient differences, whether it is for activities of daily living, cognitive and emotional status, or urologic function. Although these metrics have been applied successfully in orthopedic and thoracic surgery (61–63) and can have predictive value for longer-term outcomes (64–68), multidimensional assessment and perioperative functional assessment are largely lacking in the surgical literature. Preoperative functional assessment is important because the surgical goal should be to return the patient to at least the preoperative activity level. Tools such as the Short-Form Health Survey 36, with subscales for variables such as physical and emotional health, pain and health perception, and social functioning, can be used to measure health-related quality of life before and after surgery (Fig. 3). These types of multidimensional assessments have the potential to help redefine standards for the success of surgery and reset therapeutic priorities (61,62,69–71).Figure 3: Deviation from age- and gender-adjusted population-based Short-Form Health Survey 36 scores (subgroup scores by surgical procedure). ▵ = thoracic surgery for lung cancer; • = total hip arthroplasty; ○ = abdominal aortic aneurysm; dotted line = age- and sex-adjusted population-based value. Modified with permission from Blackwell Publishing: J Gen Intern Med 1997;12:686–97 (Figure 2).Preoperative cognitive and psychological evaluation of the elderly surgical patient deserves special comment. Although frank delirium or dementia at admission is very evident and is known to predict poorer acute and long-term outcome (72,73), subtle forms of cognitive impairment are much more common. Subtle forms of cognitive impairment can predict subsequent delirium (74) and worsened cognitive outcome in cardiac, orthopedic, and abdominal surgery patients (75–78). As such, a preoperative mental status examination (79) should be considered in all geriatric surgical patients. Preoperative depression and alcohol abuse are also relatively frequent and can affect outcomes (72,80,81); as with mental status batteries, a variety of assessment tools for depression are available. The effect of screening for mental status, depression, and alcohol abuse on perioperative management of elderly patients is a huge potential area of investigation. Preoperative Testing. The third area contributing to the preoperative preparation of the elderly surgical patient is preoperative testing. Although work in this area has been performed for large populations of mixed age groups, it is not clear whether preoperative screening tests have a different yield in the elderly or whether specific testing is indicated for elderly patient populations undergoing certain types of surgical procedures. In the general population, the bulk of routine tests are not indicated. Unfortunately, age-specific data are uncommon, and some small studies in elderly populations suggest a larger yield for specific tests. For the elderly surgical population, chest radiograph, electrocardiogram, and urinalysis may have a larger yield in patients undergoing certain types of procedures, even if these tests are not directly predictive of postoperative complications (82,83). In a small study of acutely ill elderly medical patients, the value of screening tests was evaluated (84). The most important finding in the screening battery was unknown urinary tract infections (16 of 50 patients; 32%). A different retrospective analysis (85) of 86 hip arthroplasty patients also determined that routine urine analysis was cost-effective in reducing hip infections in the elderly. Nutritional assessment can also be useful in subpopulations. The 44-center Veteran's Administration (VA) study found that albumin concentration was a predictor of surgical outcomes (86). However, because of wide confidence limits, laboratory assessments of nutritional status may make their application to individual patients less useful than to populations (87). As such, it may prove useful to combine laboratory tests with anthropomorphic measurements, such as body mass index, limb circumference, and weight loss (88–90). These instruments are simple and inexpensive, but their clinical yield has not been From these investigations and from work in younger become First, screening in a general population of elderly patients does not to information in the clinical Second, in a general population, the positive predictive value of on routine screening is Third, with a few screening tests have relatively little effect on the course of patient care. Despite those further research is required to better define the which certain tests should be Although the yield for routine screening is very it may be and cost-effective to for preoperative testing that are on the of types of surgery different types and of physiologic As such, the of a are to patients undergoing vascular Preoperative tests such as and can have predictive value and alter the course of care if applied to specific populations at increased risk nutritional assessment might be very useful before abdominal or orthopedic but it would have a much smaller effect for for urinary tract before orthopedic surgery or pulmonary function testing before thoracic surgery might be of laboratory testing. Because it is the of the patient and the surgical stress that specific testing might be equally indicated in a very physiologically older patient undergoing surgery and in the older patient undergoing surgery that physiologic studies in older patients will need to stratify patients as to of their risk or and specifically their with the specific surgical most common in the elderly. Preoperative In addition to an assessment of risk on population 2) functional data to help define surgical and specific information to perioperative management, the fourth of preoperative evaluation is to determine whether medical intervention is indicated before proceeding. Preoperative is an area in which relatively little geriatric research has been In specific populations undergoing the value of preoperative of cardiac and pulmonary status can be in nutritional status, preoperative or renal function has the potential to alter outcomes but has not been Preoperative management of and are other to There are also that preoperative might pain management and and delirium after some types of where success has been in these a with a specific geriatric care was Because anesthetic care is the for success are typically and are not related to mortality and of drugs and often variables such as and of the work specific to the elderly has been to evaluation of anesthetics. Although some of these studies have identified age-related alterations in the or is a drug may by 30 the clinical effect of these changes on patient outcomes is probably There is a for this of research in but research should probably be In addition to the studies on the pharmacology and in surgical patients, a area of research has been to and general for elderly orthopedic patients have been the in research in geriatric and general in elderly orthopedic patients has broad implications for research These studies have intraoperative cardiovascular in the elderly, and pain and cognitive of this literature was by Although a few studies reported that for orthopedic surgery was associated with better outcomes subsequent investigations have not this broad populations of patients Because most investigations have been for has been and trials that reported to at least 1 The to identify difference in mortality or blood loss by or general anesthetic there was a reduced incidence of in groups. of the data in and study more with the addition of additional trials and described reduced and mortality in hip patients other outcome measure The reduction in mortality was evident at or large studies have also not identified in morbidity or mortality by anesthetic in hip surgery patients. A was in the review The review by the effects of in trials that patients. A reduction in mortality and was in the with effect on mortality 1 Reductions in pulmonary respiratory depression, myocardial infarction, and renal failure also described with However, the of many of these outcomes was the analysis was on small subsets of patients. studies not for and data used that not reported in the Furthermore, studies for and orthopedic, and and information about age was Finally, it is to a practice on the of the review of because the of patients into the those spinal 2) general followed by postoperative general with intraoperative spinal and general with intraoperative From this it is difficult to determine whether the effects described in the review are and, if their is or to patients would In addition to the more outcomes several studies in orthopedic patients have the effect of anesthetic on cognitive or functional often patients for Although of the studies is study identified difference in cognitive outcome in elderly patients undergoing versus general for orthopedic The bulk of investigations identify difference Although not all studies are in be for and peripheral vascular surgery In there is a of a better outcome with a however, most investigations are retrospective or the effect of patient be the not identify an independent effect of anesthetic on The difficulty in a difference between and general has implications for the of research in geriatric First, because the most difference in the of anesthetic is whether the patient a or a general if little or difference in outcome can be the yield for outcome studies on differing anesthetics is to be Second, it that studies on anesthetic management and outcome will need to be to specific complications in patients to provide clinical Physiologic Although studies have the relationship between intraoperative physiologic management and of it appears that physiologic management a than a in The best is in cardiac in which the acute physiologic changes exceed those seen with other of Despite it has been difficult to a

Local anesthetic with monitored anesthesia care in cephalomedullary nailing of proximal femur fractures

Postanesthesia care is a costly component of overall surgical care. In the ambulatory setting, regional anesthesia has been shown for multiple surgical procedures to either decrease postanesthesia care unit (PACU) length of stay (LOS) or completely bypass it altogether. This has not been demonstrated in a large hospital setting with a complex surgical case mix. We therefore determined whether regional anesthesia was associated with a reduced PACU LOS among patients undergoing inpatient and outpatient surgery in a large tertiary-care teaching hospital. Secondary study questions included risk factors for longer PACU LOS and any possible interaction between regional and general anesthesia as it might have affected PACU LOS. We performed a matched retrospective study on patients who had surgery at our institution and were admitted to the PACU immediately after leaving the operating room. We analyzed between January 1, 2005, and January 1, 2013, with one cohort receiving regional anesthesia, with or without general anesthesia, and the other receiving no regional anesthesia. We measured the association between regional anesthesia and time to successful PACU discharge using a Cox multivariate proportional-hazards model. After controlling for potentially confounding variables, including patient age, American Society of Anesthesiologists' physical classification, and duration of surgery (using multivariate analysis), there was no difference in the time to successful PACU discharge between patients who received regional anesthesia and those who did not. However, when compared to those who received general anesthesia, regional anesthesia was associated with decreased PACU LOS. Further, there was significant effect modification between regional and general anesthesia; patients who received both regional and general were more likely to be successfully discharged faster from the PACU than patients who received only general anesthesia (hazard ratio = 1.50, 95% CI = 1.46-1.55, p < 0.001). We demonstrated that independently, regional anesthesia is not associated with a reduced PACU LOS in an unselected population at a large tertiary-care hospital, but regional is favored when compared to general anesthesia. Whether the differences are clinically important, and in what procedures they are most pronounced, would be reasonable questions for future prospective comparative trials. Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Regional Anesthesia on Outcomes After Minimally Invasive Ivor Lewis Esophagectomy

Anesthésie locale sous contrôle d’un anesthésiste pour l’enclouage des fractures du fémur proximal

ANESTHESIA has become remarkably safe, and while death and permanent damage have become rare occurrences, other sequelae of anesthesia are gaining more importance. Postoperative nausea and vomiting (PONV) still is the most troublesome adverse event encountered in the recovery room, despite advances in prevention and treatment. The incidence of PONV has remained high and has a major negative impact on patient satisfaction about the overall surgical experience. Furthermore, the ongoing trend toward ambulatory procedures has increased the focus on PONV as its occurrence may delay discharge or cause unanticipated hospital admission. General anesthesia has long been considered as causing a greater frequency and severity of PONV than regional anesthetic techniques. Recent studies investigating this time-honored dictum in a controlled manner mostly, but not unanimously, confirmed it. Accordingly, considerable effort has been invested to examine etiology, define patients at risk, and outline preventive and therapeutic strategies in patients undergoing general anesthesia. Reviews dealing with PONV have discussed almost exclusively general anesthesia and largely ignored regional anesthesia. This contrasts with the increasing popularity of regional anesthesia. A survey in Europe showed that one third of patients are undergoing regional anesthesia for their operative procedure. In France, the proportion of regional anesthesia increased from 15 to 25% of all anesthetics administered from 1980 to 1996. The number of local anesthetic and analgesic agents available for regional anesthesia has increased over the last two decades. Since the introduction of intrathecal and epidural morphine in 1979, a multitude of medications, such as synthetic opioids, 2-agonists, and cholinesterase inhibitors, have been introduced in an attempt to enhance the action of local anesthetics. The decision about their usefulness will not only rely on their effects on nerve blockade and pain relief, but also on their influence on side effects such as PONV. This review focuses on PONV in the setting of perioperative regional anesthesia. General aspects of PONV, such as physiology, patient, and perioperative factors involved are discussed. Few studies regarding these issues have been specifically devoted to regional anesthesia. Therefore, much information must be derived from investigations of general anesthesia. Specific regional anesthetic techniques and the influence of adjunctive medications on PONV are also presented. Combined general–regional anesthesia is purposefully excluded, avoiding the many variables introduced by general anesthesia. A final section is devoted to continuous peripheral nerve blocks and their possible impact on PONV.

Local anesthesia in outpatient knee arthroscopy: A comparison of efficacy and cost

Recently local/regional anesthesia has been reintroduced as an alternative to general anesthesia for thyroidectomy. This study was undertaken to analyze characteristics and outcomes of patients who had thyroid surgery performed under regional anesthesia compared with those who had thyroidectomy under general anesthesia. One hundred seventy-five consecutive patients who underwent thyroid surgery under regional or general anesthesia during a 3-year period were analyzed. Fifty-eight operations were performed under regional anesthesia and 116 under general anesthesia. Patient characteristics analyzed included age, gender, obesity, anesthesia class, and tumor pathology. Postoperative complications, including nausea or vomiting, were compared. Additionally, operative times and length of stay in each group were compared. Patient characteristics including age, gender, tumor pathology, and anesthesia class were similar in both groups. But only 2% of patients treated under regional anesthesia were obese compared with 23% under general anesthesia. Although not significant, there was a trend toward decreased incidence of nausea and vomiting in the regional group. Other complications for the regional and general anesthesia groups were equal at 3%. Two patients required conversion to general anesthesia. Complications in the general anesthesia group included one episode of transient symptomatic hypocalcemia, two patients with transient vocal cord paralysis, and one episode of hematoma. Finally, there was a statistically significant increase in total operating room time and length of stay for the general anesthesia group. Regional anesthesia is a safe alternative to general anesthesia for patients undergoing thyroid surgery. Patients who cannot communicate verbally with the surgical team or who are obese may not be ideal candidates for regional anesthesia. The use of regional anesthesia results in a decreased length of stay and similar operative and operating room times.

General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial

The purpose of this study is to evaluate the possibility of performing cochlear implant surgery under local anesthesia and sedation and to evaluate the response of patients under sedation at the time of neural telemetry, comparing the differences with general anesthesia. Twenty adult patients with bilateral sensorineural profound hearing loss submitted to cochlear implant surgery under general anesthesia and 20 patients under local anesthesia and intravenous sedation in the period from February 2011 to February 2012. The study was approved by the ethical committee of the institution. In both groups, we compared the costs of anesthesia, surgical time, time in recovery room, length of hospital stay, postoperative symptoms (pain, nausea, vomiting, and dizziness) and the degree of patient satisfaction. Besides, the reactions of the patients in the moment of the neural telemetry were also analyzed. The endpoint of this study is to establish the possibility of doing cochlear implant surgery with local anesthesia and sedation, discussing the differences and advantages over general anesthesia. By t-test variables, time in recovery room, time in hospital stay, and cost of inpatient anesthesia differ between groups, being always lower in the group of local anesthesia with sedation. The same result can be obtained using the Wilcoxon test. The symptoms of nausea, vomiting, and dizziness did not differ in the 2 groups. We conclude that the realization of the cochlear implant surgery under local anesthesia, and sedation is perfectly feasible with some advantages over general anesthesia. There were no problems during the neural telemetry performed by the time of the surgery in patients with local anesthesia with sedation.

Hospital-based second-trimester dilation and evacuation (D&E) procedures are often completed using general anaesthesia (GA) despite emerging evidence for the safety of monitored anaesthesia care (MAC). Limited data exist comparing these approaches for key clinical outcomes. This retrospective cohort study compared those who received GA versus MAC during second-trimester (14-24 weeks' gestation) hospital-based D&Es. The primary outcome was total operating room (OR) time; secondary outcomes included surgical time, anaesthetic time, post anaesthesia care unit (PACU) time, estimated blood loss, and respiratory complications. We hypothesised that MAC would reduce the total OR time. We estimated that a sample size of 63 participants in each group would detect a 15-min or greater difference in total OR time with 80% power and a significance level of 0.05. Propensity score matching was used for sensitivity analysis. During the study period, 125 patients received GA and 67 received MAC. Those receiving GA had significantly longer OR times (GA: 60.2±18.1 min vs MAC: 50.1±13.2 min, p=0.005) and greater estimated blood loss (GA: 150±286 mL vs MAC: 88±47 mL, p<0.001). No respiratory complications occurred in either group. A propensity score-matched analysis similarly found GA associated with longer OR time and higher blood loss. MAC may offer additional clinical benefits compared with GA during hospital-based D&E care. MAC reduces OR time and blood loss without compromising safety, which may optimise patient care and resource use in abortion care settings.

MORE than 50 yr ago, clinicians reported changes in mental function after anesthesia and surgery in the elderly. As these phenomena have been elucidated in subsequent years, they have been categorized into the distinct syndromes of delirium and postoperative cognitive dysfunction (POCD). These phenomena seem to be increasing in prevalence, concomitant with the increase in the number of elderly patients undergoing surgery. In this brief clinical review, we describe the presentation of, course of, risk factors for, and when applicable, management of these syndromes. Delirium and cognitive function after cardiac and neurosurgical procedures are distinct subjects beyond the scope of this review.Delirium was well described in the writings of Hippocrates 2,500 yr ago. The key diagnostic features, as described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders are (1) that it is a change in mental status, characterized by a prominent disturbance of attention and reduced clarity of awareness of the environment; and (2) that it has an acute onset, developing within hours to days, and tends to fluctuate during the course of the day. The inability to focus, sustain, and shift attention is accompanied by other cognitive symptoms (e.g ., disorientation, episodic memory dysfunction) and/or perceptual disturbances (misinterpretations, illusions, or hallucinations). Associated features include disturbances of the sleep–wake cycle and activity level, as well as affective disturbance (mood lability, anger, sadness, euphoria) and thought disorder (disorganized thinking, delusions). The symptoms of delirium are numerous, vary from patient to patient, vary within patients over time, and are shared by a variety of other disorders such as dementia, anxiety, depression, and psychosis, all of which contribute to difficulties in diagnosis.The heterogeneous presentation of delirium has led to the identification of hyperactive, hypoactive, and mixed subtypes.1,2The hyperactive form of delirium tends to be clinically obvious. The hypoactive form, however, is often unrecognized, misdiagnosed, mistaken for depression or dementia, or simply attributed to old age, because patients may seem quiet and subdued in their disorientation. Furthermore, the relation between delirium and dementia is complex, and the syndromes may overlap.1,2Delirium can be caused by, or associated with, a wide variety of conditions,1,2and the current Diagnostic and Statistical Manual of Mental Disorders system differentiates subtypes based on the presumed etiology. These are delirium due to a general medical condition , substance-induced delirium (due to medication use or toxin exposure), substance intoxication delirium (due to intoxication), substance withdrawal delirium , delirium due to multiple etiologies , and delirium not otherwise specified (for cases in which there is insufficient evidence to establish a specific etiology).Delirium in the postoperative period can be divided into emergence delirium and postoperative delirium (PD), based on the time of onset (fig. 1). Emergence delirium is seen during or immediately after emergence from general anesthesia and usually resolves within minutes or hours. It occurs in all age groups, with some predominance in children. It seems to be directly correlated with the administration of general anesthesia, because it occurs during the emergence process, mimics stage II (excitation) of ether anesthesia as described by Guedel, and usually resolves without sequelae. Emergence delirium fits the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, diagnostic criteria for a substance-induced delirium . The reader is referred to a more complete review of this subject.3After surgery, another type of delirium occurs that is not clearly related to emergence from anesthesia. Elderly patients commonly emerge from anesthesia smoothly and demonstrate coherence in the postanesthesia care unit. After a lucid interval, some patients develop a syndrome referred to as interval delirium or postoperative delirium .1,4Postoperative delirium tends to first be observed between postoperative days 1 and 3, and usually resolves within hours to days, although symptoms may persist for weeks to months. Postoperative delirium is more likely to result in complete recovery than other forms of delirium.5The term intensive care unit (ICU) delirium describes delirium that occurs in the intensive care unit, primarily in those patients requiring mechanical ventilation; it was previously referred to as ICU psychosis . ICU delirium makes no distinction between medical and surgical patients, so many cases of ICU delirium could also be classified as postoperative delirium.6There are a number of structured instruments available that can be used by a variety of personnel to diagnosis and assess delirium. Three validated methods include the Confusion Assessment Method,7the Delirium Rating Scale Revised-98,1and the Delirium Symptom Interview.1The confusion assessment method has been used for most postoperative delirium research and has been modified and validated for use in critical care patients receiving mechanical ventilation.8The reported incidence of PD is 5–15% in older adults after general anesthesia.9The reported incidence in patients undergoing surgery for hip fracture is higher, ranging from 16% to 62%, with an average rate of 35% across 12 studies of 1,823 patients.10Delirium is indeed the most common complication after hip fracture, but this patient population also has a high incidence of delirium before surgery.In elderly patients hospitalized for reasons other than surgery, the risk of developing delirium while hospitalized is predicted by an interaction between vulnerability factors present at the time of hospitalization and noxious injuries, or precipitating factors that occur during hospitalization.2Among the predisposing risk factors identified are vision impairment, severe illness, cognitive impairment, and serum urea nitrogen:creatinine ratio of 18 or greater. The precipitating factors identified are use of physical restraints, malnutrition, more than three medications added 24–48 h before the onset of delirium, use of a urinary bladder catheter, and iatrogenic events, including fluid and electrolyte abnormalities and infections.2Studies in surgical patients have identified age 70 yr or older, history of delirium, history of alcohol abuse, and preoperative use of narcotic analgesics as preoperative predisposing risk factors for PD.11Preoperative depression also seems to be a risk factor for postoperative delirium.12Perioperative risk factors include greater intraoperative blood loss, more postoperative transfusions, postoperative hematocrit less than 30%, and severe postoperative pain.13There are contradictory reports on the role of perioperative hypotension and hypoxemia in the development of PD. The role that postoperative pain plays in the development of PD is not attributable to method of analgesia, type of opioid analgesia, or cumulative opioid dose.14Drug effects are considered an important cause of delirium. In medical patients, the most important drug classes associated with delirium are the sedative–hypnotics, narcotics, and anticholinergics,1all of which are routinely used in perioperative care. The role of benzodiazepines is controversial.1Lorazepam has been specifically associated with the development of delirium in the ICU.15There is extensive literature investigating the proposition that regional anesthesia would be associated with less delirium than general anesthesia; however, the majority of these studies show no difference.16,17The underlying pathophysiology of delirium in general, and PD specifically, remains elusive. Delirium is the behavioral manifestation of diffuse cortical dysfunction and is associated with diffuse slowing of background activity in the electroencephalogram (except in cases of alcohol withdrawal, in which there is an increase in fast wave activity).1It is also associated with disturbances in a wide variety of neurotransmitter systems, and disruption of cholinergic transmission seems to be especially important.2Toxicity from anticholinergic agents mimics the electroencephalographic and behavioral aspects of delirium and is reversed by physostigmine. Serum anticholinergic activity is associated with delirium in postoperative patients.18Other potential mediators include melatonin, norepinephrine, and lymphokines.1,2Postoperative delirium is associated with increased morbidity (including risk of injury), mortality, duration of hospital stay, nursing home placement, and technical (nonphysician), consultant, and nursing costs.19In a recent study, duration of hospital stay for surgical patients was 6.0 days for those who developed delirium and 4.6 for those who did not.19The average additional in-hospital cost per surgical patient with PD was $2,947, which equates to more than $2 billion additional healthcare dollars per year in the United States.It is possible to prevent PD in some patients using safe and effective interventions for systematic detection and management of predisposing factors.1The most widely studied intervention program to prevent delirium in elderly medical patients is the Hospital Elder Life Program.20Interventions are targeted towards six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Some of the specific interventions include frequent presentation of orienting information (such as prominent display of the date, time, schedule, and names of hospital personnel), cognitive stimulation activities, physical exercise, use of visual aids and adaptations, use of auditory amplifying devices, nonpharmacologic methods to promote sleep (such as drinking warm milk before bed, relaxing music, back massage, noise-reduction strategies), and feeding and fluid assistance. Other protocols have focused on coordinated geriatric services, geriatric–psychiatric consultations, and patient and family education. A series of randomized and nonrandomized trials indicate that a substantial absolute risk reduction (in the range of 13–19%) can be achieved.1,2A trial of proactive geriatric consultation in hip fracture patients reduced delirium by more than one third and reduced cases of severe delirium by more than one half.21Treatment of agitation poses a special problem. Agitation puts the patient, visiting family, and staff at risk for physical injury and interferes with administration of normal postoperative care, but current treatment options are less than optimal. Attempts should be made to avoid the use of physical restraints, which may worsen delirium and agitation. Pharmacologic therapy is used specifically to decrease agitation.22Haloperidol, a typical antipsychotic dopaminergic antagonist, is administered to adults at a dose of 0.5–1 mg intravenously every 10–15 min until the agitated behavior is controlled.∥Intramuscular dosing is less desirable but can be employed using 2–10 mg, waiting 60–90 min between doses. By careful dosing, practitioners should limit the degree of haloperidol's sedative side effect, because this drug has an extended half-life in the elderly (up to 72 h) and deep sedation can last for several days. It is important for the clinician to recognize that haloperidol can be useful in the immediate management of agitation but does not alter the duration of delirium. Newer antipsychotic medications, such as ziprasidone and olanzapine, are administered intramuscularly and are reportedly effective in the management of acute agitation but have not been tested in patients with either medical or surgical comorbidities.22Although most typical antipsychotics increase the corrected QT interval and may predispose to arrhythmias, haloperidol has a relatively lower propensity to do so. Cases of sudden death are rare and have not been clearly related to haloperidol.22Although it is reasonable to assume that benzodiazepines would be an effective treatment for agitation in the context of PD, anecdotal experience has shown that these medications may have a paradoxical effect in elderly patients and may worsen agitation.22If alcohol withdrawal is suspected to be the underlying cause of delirium, however, benzodiazepines are the treatment of choice.The term postoperative cognitive dysfunction (POCD) describes a deterioration of cognition that is temporally associated with surgery. As opposed to delirium, in which pathognomonic behavior must be detected, detecting, assessing the severity of, and characterizing POCD depends on valid assessments of preoperative and postoperative cognitive function. The neuropsychological examination measures the information processing abilities of the brain through a battery of tests (assessing attention, perception, verbal abilities, learning and memory, and abstract thinking) that are sensitive to the effects of brain injury and disease.23The wide variability in normal human cognitive capacities associated with aging and a possible incidence of preexisting mild cognitive impairment in the elderly make baseline (i.e ., preoperative) measures a critical component of these evaluations. In the absence of baseline data, it is impossible to associate low postoperative test scores to surgical, anesthetic, or illness variables with certainty. Subjective self-reported cognitive symptoms do not substitute for objective cognitive testing, because a poor relation between the two types of data has been demonstrated repeatedly.24There are a number of methodologic inconsistencies among studies that make the limited literature on POCD difficult to interpret. These include the selection of test instruments, timing of postoperative testing, inclusion and exclusion criteria, the inherent variability of cognitive testing, and most fundamentally, the operational definition of POCD.Mental status screening instruments such as the Mini-Mental State Examination are useful for detecting frank dementia but lack the sensitivity and specificity required to detect milder or more selective forms of cognitive impairment.23High-functioning patients who have experienced a mild decline in cognitive function and patients with "focal," as opposed to "diffuse," cognitive dysfunction may achieve high Mini-Mental State Examination scores. Cognition is not a unitary process, but rather is the result of activity in multiple complex, distributed, and interacting neuronal circuits that underlie specific information processing functions. There is no single measure of cognitive status; therefore, comprehensive neuropsychological assessment requires that a battery of tests assessing a variety of cognitive domains must be used. There are, however, a wide variety of tests available, which differ in their test–retest reliability, sensitivity, specificity, and the degree to which they are subject to practice effects.Another methodologic inconsistency among the studies is the timing of postoperative cognitive testing. In general, studies measuring cognitive function shortly after surgery find a much higher incidence of POCD than studies measuring cognitive function weeks to months after surgery. Longitudinal studies have the problem of attrition, which does not occur randomly but is influenced by the postoperative health status, functional status, and possibly the cognitive status of the patient. Patients who develop POCD may be more likely to drop out of the study, thus underestimating the true incidence of POCD.It is also important to consider the subject inclusion and exclusion criteria when interpreting study findings. Recently, the term mild cognitive impairment has come to represent a transitional zone in the spectrum of cognitive function from normal aging to progressive dementing conditions, such as Alzheimer and cerebrovascular diseases. Unfortunately, patients with preoperative mild cognitive impairment have not been differentiated in studies of POCD. Therefore, there is no information available concerning the impact of surgery and anesthesia on this subset of patients that may be at greatest risk for POCD. There is no evidence that anesthesia and surgery increase the incidence of Alzheimer disease.One of the greatest problems facing the investigation of postoperative cognitive function is the absence of a consensus regarding the operational definition of POCD. Variations in the methods that different groups have used to define deterioration in cognitive function in part underlie the difficulty in comparing studies. Furthermore, few studies use control groups and take practice effects into account.25The percent change method involves converting the preoperative to postoperative difference score into a percent of baseline score, i.e ., (postoperative score − preoperative score)/preoperative score. This method generates continuous data, which can then be averaged across patients for group comparisons. The use of group mean analyses, however, is discouraged, because a subset of subjects experiencing significant deterioration may be masked when other subjects exhibit improved performance over time. The SD method involves identifying patients who experience a postoperative decline of some criterion number of SD units (Z scores). The International Study of Postoperative Cognitive Dysfunction (ISPOCD) studies (see below) required a 2-SD decline to qualify as POCD. Limitations of the SD method include the following: (1) in patients with low baseline scores, it may not be possible to decline by more than 1 SD (i.e ., floor effect); and (2) the absolute magnitude of change in raw test scores required to meet the criterion differs between studies, because they are derived from the preoperative test scores of the baseline sample. A third strategy involves identifying patients who experience a specific percentage (e.g ., 20%) decline from baseline of at least a specific percentage (e.g ., 20%) of the tests administered. A limitation of this technique is that patients with lower preoperative test scores require a smaller decline in raw score to meet the 20% criterion. It should be noted that the methodology used by ISPOCD is a subset of the general assessment technique referred to as a reliable change index . Lewis has recently explored a number of issues related to the use of this technique.26In 1998, Möller et al .27presented the first of a series of multicenter studies from the ISPOCD that primarily included European centers. Information from the ISPOCD studies is available at the ISPOCD Web site.#The ISPOCD1 study tested the hypothesis that insufficient oxygen delivery to the brain, as assessed by the presence of hypotension and/or hypoxemia, is a causative factor for POCD. The study included 1,218 patients, aged 60 yr or older, who underwent major abdominal, noncardiac thoracic, or orthopedic surgery during general anesthesia. Patients were tested preoperatively and at 1 week and 3 months postoperatively. Test results were compared with a total of 321 controls recruited from the United Kingdom, 11 centers in and centers in Patients were classified as experiencing cognitive dysfunction when two scores in tests by or the average score greater than 1 week of patients experienced a decline in cognitive compared with of control 3 months of patients experienced a decline to preoperative of compared with of number of subsequent studies have described cognitive impairment within the first days after surgery and et al a rate of POCD of at months after surgery, although in the absence of a control the is to A study that patients at 1 and yr that the rate of POCD to which was not it seems that elderly patients deterioration shortly after surgery and anesthesia at 2–10 with such that the incidence at 3 at at 1 to from control subjects by 1 important are that (1) the of patients to drop out of such studies, the may the true incidence of and (2) the clinical course of an patient be clearly from this in that there is inconsistency between the In the ISPOCD studies, less than of the who were classified at POCD at 3 months decline at 1 week (i.e ., POCD at 1 week did not POCD at 3 a of the data from the ISPOCD studies, et al . to the impact of test–retest variability on the of that variability in cognitive results could after surgery would be as frequent as This that cognitive decline at 1 week but that there was no significant change at 3 months. study be required to impairment is an important clinical in cognitive is an important factor that to the low between that should be in studies of all of the studies to have that age is a risk factor for POCD. of patients aged yr undergoing major surgery a but significant decline in cognitive function at 1 week that was no at 3 months the ISPOCD that POCD is primarily a problem of elderly surgery seems to be the for POCD. A study comparing patients undergoing general anesthesia and surgery with at least a single hospital stay with patients who underwent general anesthesia for surgery that surgery was not associated with significant major surgery, postoperative cognitive dysfunction at 1 week was associated with increased age, increased duration of anesthesia, of postoperative and age was a significant risk factor for POCD at 3 postoperative pain has also been associated with postoperative cognitive function. In a study of patients aged who underwent surgery, greater pain on postoperative 1 was associated with performance on some neuropsychological degree of preoperative pain was not related to preoperative cognitive test date, the of POCD remains in neurotransmitter and system have all been but the has been general anesthesia. anesthesia is a with multiple medications, many of which are to cause delirium. The method of the potential of general anesthesia to POCD has been randomized trials of general regional anesthesia. studies that of anesthesia is not an important factor in the development of is in greater such different as regional and general anesthesia have impact on postoperative cognitive function in clinical studies, there are studies that general agents have effects on and of this to the clinical syndromes described require significant additional and are potential etiologies of POCD for which potential (e.g ., that were in the first ISPOCD study the role of hypotension and hypoxemia as potential was by continuous and blood was by the perioperative high of hypoxemia and condition was associated with POCD. may additional into this problem. research is to the role of in the of of the is associated with the development of Alzheimer but has not been to be an important of POCD in general for either a to POCD or a of POCD is but all such In studies of cardiac surgery patients, but not may be useful as a of research including that for different aspects of (in cardiac and require substantial additional research to establish clinical is that general anesthesia, which specifically the brain, as compared with regional anesthesia, which primarily the or would be associated with different of POCD. in a series of relatively studies that patients undergoing general anesthesia, but not anesthesia, were at greater risk for et al an randomized study of POCD that used neuropsychological This study compared the effect of general anesthesia on the incidence of POCD in patients undergoing total assessment was days preoperatively and 1 week and months postoperatively. mean scores for of the measures were compared between the two anesthesia groups, but no significant were observed postoperatively. In the of patients clinically important for test by were of patients a decline in cognitive function months after surgery, but no significant were between the anesthesia As this was a there was no control group for Recently, et al a comprehensive review of studies that the of anesthesia and that it does not the incidence of the of PD and it is important to consider that there may be an between Postoperative delirium may be a of POCD or an Patients who developed delirium in the ISPOCD1 study were not the patients who developed POCD. In ICU patients, delirium does seem to be of term cognitive majority of studies to have focused on either PD or POCD. In the studies that for PD and POCD should on this system dysfunction after anesthesia and surgery is primarily a problem of the elderly. The of an aging population and in anesthesia and surgery has led to in the number of elderly patients undergoing surgery. It is therefore, that postoperative dysfunction an common delirium is an diagnostic that requires research to as well as to effective and treatment There are available that seem to postoperative delirium. of these may be difficult limited however, assessment of patients for delirium has a of care in some European and should be with the and management of to PD, the that to define the presence or absence of POCD are The are not regarding the of cognitive that are associated with do they regarding the degree of dysfunction that is clinically illness requiring hospitalization may be associated with cognitive the that cognitive decline occurs as a of illness rather than it related to surgery and/or anesthesia. There are patients who significant after surgery and anesthesia. study, of clinical with mild cognitive impairment be for practitioners to the of cognitive dysfunction after noncardiac dysfunction is a health problem of study to the risk and and underlying should the current status of postoperative delirium and cognitive dysfunction and to prevent and delirium as studies to postoperative function.

Adult strabismus surgery under propofol sedation with local versus general anesthesia.