Regional Versus General Anesthesia in the Elderly: A Nuanced Approach

BackgroundBasilic transposition arteriovenous fistula (BT AVF) is a viable option for dialysis-dependent patients, which can be performed under either general or regional anesthesia. Regional anesthesia is reported to cause vascular dilatation during the perioperative period, leading to improved fistula success. Regional anesthesia is also considered safe as compared to general anesthesia in terms of hemodynamic stability. Limited and conflicting data are available comparing regional versus general anesthesia in terms of fistula maturation and patency. We aimed to compare the maturation, one-year patency rates, and complication rates in patients undergoing single-stage BT AVF in regional versus general anesthesia.MethodsThis retrospective observational study was conducted on patients undergoing single-stage BT AVF from January 2016 to December 2019. Patients were divided into regional (RA) vs. general anesthesia (GA) groups and compared in terms of maturation, one-year patency, and perioperative complication rates.ResultsOut of 152 patients, 110 (72.37%) were in GA while 42 (27.63%) were in the RA group. Elderly, female, diabetic, ischemic heart disease, and American Society of Anesthesiologists (ASA) class IV patients were more in the RA group. Other comorbid and vascular access-related factors were comparable between the groups. A trend toward higher maturation rates (97.6% vs. 92.1%) and one-year patency rates (62.5% vs. 56.6%) was observed in the RA vs. GA group, however, the difference did not attain statistical significance, p=0.359 and p=0.327, respectively. The rate of access abandonment was higher in the GA group (43.4% vs. 37.5%). The most prevalent cause of abandonment was death in the RA group while it was access failure in the GA group. Overall complication rates were comparable between both groups (20.2 % vs. 17.5%, p=0.816).ConclusionRegional anesthesia is a useful technique with potentially improved maturation and patency rates. Nevertheless, an assumed benefit of regional anesthesia in terms of anesthesia-related complications was not observed.

In order to determine patients' attitudes toward and experiences with regional anesthesia (RA) and general anesthesia (GA), we surveyed 266 citizens of Mainz and 353 patients who received RA or GA for surgery on their extremities. The nonsurgical population had partly outdated and distorted attitudes toward, and experiences with, anesthesia. RA was remembered as unpleasant more often than GA. GA was considered the more pleasant, but riskier method. Comparably frequent, but different fears were expressed toward each technique. GA was preferred more often. The majority of patients for surgery questioned the anesthesiologist preoperatively. The fear of RA could frequently be eliminated by an informative premedication discussion. Rarely, the performance of RA and induction of GA were felt as unpleasant. Even though the majority of patients were awake under RA, few experienced surgery as unpleasant. Following RA, the patients were more alert during the day of surgery. Postoperative pain started a few hours later following RA. The incidence of postoperative vomiting, headaches, and disturbances of micturition were not different following RA and GA. Throat complaints were more common following GA, back pain following RA. During the premedication visit, the anesthesiologist should be aware that patients bring partly outdated and distorted attitudes toward anesthesia but that overall they are comparably satisfied with RA and GA.

The comparison between regional anesthesia and general anesthesia is a continually evolving debate. Each technique has pros and cons, and the selection of anesthetic approach is highly dependent on specific indications, patient comorbidities, and type of surgery. Elderly patients, who are more likely to have multiple comorbidities and overall frailty, require a more nuanced approach. In this article, we review the literature for differences in various outcomes between regional anesthesia and general anesthesia. We summarize systematic reviews, meta-analyses, and literature reviews, focusing on results in the past decade. Notable differences in outcomes are discussed, especially those pertinent to the geriatric population. Regional anesthesia may be associated with multiple benefits despite differences in clinical practice over the years. Further research is needed to elucidate these benefits.

Background and ObjectivesThe establishment at our center of a dedicated regional anesthesia service in 2008–2009 has resulted in a marked increase in single-shot brachial plexus blocks (sBPBs) for ambulatory wrist...

Incidence of Shunting During Carotid Endarterectomy: Regional Versus General Anesthesia

There are only a few prospective clinical trials investigating the effects of different anesthetic techniques on clinical outcomes after lumbar spine surgery. The purpose of this study was to evaluate clinical outcomes in patients receiving general (GA) and regional anesthesia (RA) for lumbar spine surgery. This was a single-center, 2-arm, trial in which 100 patients undergoing lumbar spine surgery were randomized to receive either RA or GA (50 per group). The primary endpoint was morphine consumption during the first postoperative 48 hours. In addition, anesthesia time, transition time (defined as time from end of surgery to admission to the postoperative anesthesia care unit), visual analogue scale (VAS) for pain, and patient satisfaction at hospital discharge were recorded. There was no difference in the primary endpoint (cumulative morphine consumption at 48 h) between the 2 anesthesia types. Anesthesia and transition times were significantly shorter in the RA compared with the GA group-anesthesia time 125.4±23.6 minutes for GA versus 99.4±13.5 minutes for RA, transition time 22.5 minutes for GA versus 10.0 minutes for RA (both P<0.001). The VAS for pain on arrival to the postoperative anesthetic care unit was lower for patients who received RA compared with GA (crude and adjusted, both <0.001). 84% of patients in the RA group were completely satisfied compared with 74% in the GA group (P<0.001). There was a significant difference in the sex analysis for VAS for pain over time; females reported higher VAS for pain from the preoperative assessment to 6 weeks after the operation (P<0.001). There was no difference in postoperative morphine consumption in patients receiving GA and RA for lumbar spine surgery. RA was associated with shorter anesthesia and transition times, lower VAS for pain at arrival at the postoperative anesthesia care unit, and higher patient satisfaction at hospital discharge.

19 - Is There a Best Approach for Patients With Difficult Airways: Regional Versus General Anesthesia?

T he 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.

Regional Versus General Anesthesia in Pediatric Surgery Patients: A Clinical Perspective

Hip and Knee Arthroplasty: Regional Versus General Anesthesia

Regional Versus General Anesthesia in Surgical Patients With Chronic Obstructive Pulmonary Disease

Acute Postoperative Pain: Regional Versus General Anesthesia

Is There a Difference in Outcome of Total Joint Arthroplasty When Regional Versus General Anesthesia Are Used?

Perioperative Outcomes after Regional Versus General Anesthesia for Above the Knee Amputations

Regional Versus General Anesthesia for Carotid Endarterectomy: The American College of Surgeons National Surgical Quality Improvement Program Perspective