Multimodal Anesthesia Research Articles

Maxillary nerve block as part of a multimodal anaesthesia in a lactating red-necked wallaby (Macropus rufogriseus) undergoing partial maxillectomy

A partial maxillectomy was performed in a four-year-old, 12-kg lactating female red-necked wallaby or Bennett’s wallaby (Macropus rufogriseus) with a diagnosis of oral necrobacillosis or ‘lumpy jaw disease’. After intramuscular...

Optimization of perioperative management of proximal femoral fracture in the elderly.

Proximal femoral fracture in elderly subjects is a major event that is life-threatening in the medium-to-long term. Advanced age, male gender and number of comorbidities largely account for high mortality and require geriatric expertise. Protein-energy malnutrition and bone demineralization increase mortality. Mortality can, on the other hand, be reduced by acting on two variables accessible to medical intervention: daily activities and nutritional status. Functional and neurocognitive assessment allow the risk of dependency to be evaluated, and global geriatric work-up can prevent sudden breakdown of homeostasis. In the emergency setting, pain is to be alleviated, polymedication and anticoagulation therapy checked, and instability (notably cardiac and pulmonary) and confusion syndrome screened for on geriatric and anesthesiologic opinions. Surgery should be implemented without delay, within 48hours of admission, preferably using multimodal anesthesia. The technique should be geared to allow early weight-bearing and mobilization. The most comprehensive care plan involves team-work between emergency physicians, surgeons, orthopedic specialists, anesthesiologists, geriatricians, pharmacists, rehabilitation specialists and nursing staff, to reduce mortality and readmission and improve functional results. Post-fracture coordination seeks to prevent falls and further fractures and to treat bone demineralization.

Ring Block of the Penis: A Proven Addition to Multimodal Pain Relief for Newborn Circumcision.

* Abbreviations: EMLA — : eutectic mixture of local anesthetic RB — : ring block Pain in the neonatal period has both acute and chronic consequences. Increased awareness regarding the negative aspects of using narcotic analgesics to control procedural pain in infants and children favors the use of alternative techniques. In healthy neonatal boys, circumcision represents their first exposure to a procedure with the potential for significant pain. The goal of everyone involved in the performance of neonatal circumcisions must be to use techniques that allow this procedure to be performed with minimal discomfort to the infant while at the same time optimizing the risk/benefit ratio between the provision of anesthesia or analgesia and patient safety. In this month’s edition of Pediatrics , Sharara-Chami et al1 present their study entitled “Combination Analgesia for Neonatal Circumcision: A Randomized Controlled Trial,” in which they demonstrate that multimodal anesthesia and analgesia techniques are superior to the topical of a eutectic mixture of local anesthetic (EMLA). The authors found that the best combination for newborn circumcision anesthesia and analgesia was the use of EMLA cream, followed by sucrose administration and then a penile block with plain lidocaine before the onset of the procedure. Sharara-Chami et al1 used EMLA … Address correspondence to David A. Rosen, MD, FAAP, Department of Anesthesiology, West Virginia University, PO Box 8255, 1 Medical Center Dr, Morgantown, WV 26506-8255. E-mail: rosend{at}wvumedicine.org

232 - Is the Use of Multimodal Anesthesia for Postoperative Pain Control Effective in Patients Undergoing One– or Two-Level Anterior Lumbar Interbody Fusions with Posterior Percutaneous Pedicle Screw Instrumentation?

232 - Is the Use of Multimodal Anesthesia for Postoperative Pain Control Effective in Patients Undergoing One– or Two-Level Anterior Lumbar Interbody Fusions with Posterior Percutaneous Pedicle Screw Instrumentation?

Cytokine response after radical operations for tumors of the colon

In cancer patients, who underwent wide planned surgical operations as to a tumor of the colon, in postoperative period immune suppression may be caused by an inflammatory reaction that directly influences the number of postoperative complications.Aim of research – the comparative assessment of the influence of postoperative anesthesia methods on the cytokine response of an organism.Materials and methods. There were examined 102 patients with tumors of the colon. All patients after operations were hospitalized at the department of intensive care. The control group (N=53) was anesthetized by non-steroid anti-inflammatory preparations together with opiates. The studied group (N=49) received the continuous prolonged epidural analgesia within multimodal anesthesia. There were studied the pain level (by 10-point visually analogous scale), influence on the change of anti-inflammatory and inflammatory cytokines on the cytokine response. The levels of IL-1β, IL-4, IL-10 and TNF were studied.Results. The study of cytokines level demonstrated that at 3 day after the operation in the studied group of patients (continuous prolonged epidural analgesia) the level of anti-inflammatory cytokines decreased and the level of inflammatory ones increased. It allows to note the positive influence of the continuous prolonged epidural analgesia on the cytokine response in the organism of patients, operated as to colon tumors.Conclusions. The prolonged continuous epidural analgesia within multimodal anesthesia provides the adequate postoperative analgesia after operations as to colon tumors. In favors the stable anesthesia and excludes periodical exacerbations of pain syndrome. It stimulates anti-inflammatory cytokines production, decreases the cytokine response of the organism to the operative trauma after the surgical treatment of colon tumors

Can ultrasound-guided subcostal transverse abdominis plane block be used as sole anesthetic technique?

Subcostal transverse abdominis plane (TAP) block anesthetizes area of the abdomen with cutaneous innervation of T6–T10 dermatomes. These abdominal field blocks become very advantageous when cardiac patient presents for noncardiac surgeries as sole anesthetic or as a part of multimodal anesthesia. A 58-year-male came for open surgical repair of subxiphoid incisional hernia developed post coronary artery bypass grafting (CABG). Echocardiography showed hypokinesia of left ventricle (LV) in the left anterior descending (LAD) artery territory, dilated LV, and ejection fraction of 30%, and coronary angiography after 6 months of CABG showed 70% stenosis of LAD. Surgery was successfully accomplished under ultrasound-guided bilateral subcostal TAP block except for a brief period of pain and discomfort when hernia was being reduced which required narcotic supplementation. The patient remained comfortable throughout the procedure as well as 24 h postoperatively without any analgesic supplementation. Thus, subcostal TAP block can be a safe alternative to neuraxial or general anesthesia for epigastric hernia repair in selected patients.

The experience with the application of multimodal anesthesia in pediatric ophthalmology for the treatment of the children presenting with retinopathy of prematurity

Purpose. The objective of the present study was the comparative evaluation of the effectiveness and adequacy of the regional anesthetic medication as a component of multimodal anesthesia applied in ophthalmological surgery for the treatment of the children presenting with retinopathy of prematurity. Materials and methods. The study included the comparative analysis of anesthetic support in 120 cases of the surgical intervention for the treatment of retinopathy of prematurity in the children at the age varying from 1 month to 1 year. The comparison involved three groups of the patients. The main group was comprised of the children treated with the non-steroidal anti-inflammatory agent paracetamol in the combination with retrobulbar (peribulbar) or infraocular anesthesia and the peripheral van Lint block (14 anesthesias). The control group 1 consisted of the children treated with the narcotic analgesic fentanyl (46 anesthesias) while the control group 2 was composed of the children (n = 60) given inhalation anesthesia with the use of oxygen, nitrous oxide, and sevorane). The principal hemodynamic characteristics including the heart rate, mean, systemic, systolic, and diastolic arterial pressure as well as electrocardiogram, concentration of inhalation anesthetics, capnometry, and the blood oxygenation level were monitored. In addition, the severity of pain and the frequency of apnoea during the postoperative period were evaluated. Results. The application of regional anesthesia with the use of a 0.2% solution of naropin in ophthalmological surgery for the treatment of retinopathy of prematurity in the children ensures strong enough anesthetic effect in the absence of the additional therapeutic interventions that might influence the hemodynamic characteristics and allows to refuse to use narcotic preparations as well as reduce the concentration of inhalation anesthetics. This method improves the course of the postoperative period by virtue of the long-standing anesthetic effect, rapid restoration of consciousness, the absence of postoperative apnoea, reduction of the postoperative starvation time, and the promotion of accelerated rehabilitation of the patients.

Multimodal Anesthesia for Glaucoma Surgery in a Child with Mitochondrial Disease and Malignant Hyperthermia

Multimodal Anesthesia for Glaucoma Surgery in a Child with Mitochondrial Disease and Malignant Hyperthermia

Comparación de dos combinaciones de anestésicos inyectables utilizados en laparotomía medial para recuperación de embriones en ovejas criollas colombianas

En el campo, el uso de anestésicos halogenados es difícil, por lo que el uso de agentes inyectables es una herramienta esencial de la práctica anestésica. El objetivo del presente estudio fue comparar dos protocolos de anestésicos inyectables multimodales y determinar el adecuado protocolo para realizar una laparatomía medial y recuperar embriones en ovejas. Se utilizaron 16 ovejas criollas adultas y sanas. Los animales se asignaron al azar para recibir xilazine 0,2 mg/kg PC IM y de ketamina 10 mg/kg PC IV (XK grupo) o una infusión continua de solución al 5 % de xilazine (50 mg), ketamina (500 mg) y de guaifenesina (500 mL) a una tasa de 2,2 mL/kg/h IV (grupo XKG). Frecuencia cardiaca y respiratoria, motilidad del rumen y temperatura corporal se evaluaron antes de la anestesia, después de la inducción y durante la recuperación. La inducción se evaluó según los espasmos musculares, nistagmo y movimiento de las extremidades. La anestesia se valora en función del tiempo, relajación mandibular, sensibilidad cutánea y reflejos. La recuperación se evaluó a una escala de agente anestésico (0-10). Los parámetros cardiorrespiratorios disminuyeron por debajo de los valores basales después de la inducción de anestesia en ambos grupos. Entre los grupos, hubo una diferencia significativa en el tiempo de decúbito (XK: 9,06 ± 0,73 min; XKG: 7,81 ± 0,53 min) y la recuperación (XK: 53,13 ± 5,3 min; XKG: 98,38 ± 5,71 min). Los cambios en el sistema cardiopulmonar fueron similares en ambos regímenes anestésicos, y estaban dentro de rangos clínicos aceptables. Se concluye que, en intervenciones quirúrgicas cortas, la anestesia xilacina-ketamina proporciona una rápida inducción, el mantenimiento de los parámetros fisiológicos dentro de los límites óptimos y una recuperación rápida.

Current Strategies in Anesthesia and Analgesia for Total Knee Arthroplasty.

Total knee arthroplasty is associated with substantial postoperative pain that may impair mobility, reduce the ability to participate in rehabilitation, lead to chronic pain, and reduce patient satisfaction. Traditional general anesthesia with postoperative epidural and patient-controlled opioid analgesia is associated with an undesirable adverse-effect profile, including postoperative nausea and vomiting, hypotension, urinary retention, respiratory depression, delirium, and an increased infection rate. Multimodal anesthesia--incorporating elements of preemptive analgesia, neuraxial perioperative anesthesia, peripheral nerve blockade, periarticular injections, and multimodal oral opioid and nonopioid medications during the perioperative and postoperative periods--can provide superior pain control while minimizing opioid-related adverse effects, improving patient satisfaction, and reducing the risk of postoperative complications.

Perioperative opioids aggravate obstructive breathing in sleep apnea syndrome: mechanisms and alternative anesthesia strategies.

Opioids induce and increase the severity of most sleep-disordered breathing in all patients, but especially in morbidly obese patients. Discussed herein are the direct impact and mechanisms of opioids on inducing and exacerbating obstructive sleep apnea syndrome in normal and morbidly obese patients. Respiratory depression is a larger problem than obstructive sleep apnea syndrome during the first night after an opioid anesthesia because of the reduced amount of deep sleep and rapid-eye-movement sleep. Acute tolerance to the analgesic effects of opioids can be observed after one anesthetic opioid dose, although tolerance to the side-effects of opioids develops more slowly. Therefore, it makes sense to avoid all opioids intraoperatively. A recently developed multimodal nonopioid anesthesia method may prevent development of acute tolerance and facilitate postoperative pain management with less opioids and sleep-disordered breathing. A multimodal nonopioid anesthesia method avoids the necessity for intraoperative opioids, reduces the need for postoperative opioid use, and improves analgesia with less narcotic.

Application of Multimodal Anesthesia in Surgical Interventions for Lung Cancer

Objective. To prove pathogenically the reasonability of multimodal anesthesia in patients with lung cancer to improve the efficacy of pain management. Materials and methods . 74 patients (59 men and 15 women) aged 46 to 60 years with lung cancer were examined and treated. 42 patients (the main group) underwent surgery under multimodal anesthesia accompanied with epidural blockade, and 32 patients (the comparison group) were subjected to a surgical intervention under inhalation and intravenous anesthesia with mechanical ventilation. The surgeries including atypical lung resection, lobectomy and pneumonectomy were performed. In preoperative, intraoperative and early postoperative periods, the systemic hemodynamics parameters were determined; adrenaline, noradrenaline, dopamine, cortisol, insulin and glucose were measured in plasma, and acidbase balance parameters — in arterial blood. Pain intensity was assessed by the visual analog scale. Data processing was carried out using Microsoft Exсel 2000, STATISTICA6.0 and Biostat software. Normality of distribution was assessed by KolmogorovSmirnov test. Since the ordered sample did not follow the normal distribution law, the data are presented as a median (Me) and interquartile amplitude (25 and 75 percentiles). Results. It has been found that the most significant pathogenic factor in patients being operated due to lung cancer under the standard anesthesia is the expressed activation of the sympathoadrenal system due to the impact of surgical stress. This is manifested by disorders of the central hemodynamic parameters, such as metabolism, nociception and oxygen balance. In surgeries carried out under multimodal anesthesia, the minimal changes of basic homeostasis parameters are registered; these changes are shorttermed, compensated and reversible. Pain syndrome upon completion of surgery and in the early postoperative period is either absent or mild. C onclusion . It is more expedient to perform surgeries to remove malignant tumors in the lungs under the multimodal anesthesia, because these interventions are distinguished by high traumatic rate and having a «fine line» between compensation and decompensation of the basic vital functions in the perioperative period.

Continuous caudal epidural analgesia for perioperative pain control after bilateral mastectomy in a mare

An epidural catheter was used to provide perioperative analgesia as part of a multimodal balanced anaesthesia and analgesia in a mare undergoing a bilateral mastectomy. Despite development of severe hypoxaemia...

Влияние мультимодальной анестезии на гемодинамический профиль и кислотно-основноесостояние в раннем послеоперационном периоде у пациентов, оперированных по поводу новообразований лёгких

This work presents the effects of multimodal anesthesia with neuraxial blockade on the basic
 parameters of central hemodynamics in patients operated for lung tumors, revealed by method of terapolar
 rheovasography by Kubicek (systolic blood pressure, diastolic, average heart rate, ejection fraction, minute
 volume of blood circulation, cardiac index, oxygen delivery index, the index of the total peripheral vascular
 resistance), as well the effects on acid‐base balance of arterial blood in the immediate post‐operative period.
 The level of antinociceptive protection was assessed by visual analogue scale. Comparison of results of patients
 operated by means of multimodal anesthesia and the patients, operated in an inhalation intravenous
 anesthesia with artificial lung ventilation and peri‐operative analgesia by opioid analgesics has revealed that
 the hemodynamic profile of the first group of patients is characterized by stability of the basic parameters
 such as blood pressure and heart rate, the lack of a pronounced reduction of the ejection fraction and stroke
 volume of the heart, despite vasoplegia caused by epidural blockade. The level of partial oxygen tension of
 arterial blood was decreased in the early postoperative period, but it was in the normal limits and he was
 statistically significantly higher than in the comparison group that can help reduce the risk of post‐operative
 complications. Significantly lower level of pain indicates adequate antinociceptive protection of patients.

Multimodal anesthesia with the addition of methadone is superior to epidural analgesia: A retrospective comparison of intraoperative anesthetic techniques and pain management for 124 pediatric patients undergoing the Nuss procedure

BackgroundThe Nuss procedure corrects pectus excavatum by forceful displacement of the sternum with metal bars. Optimal pain management remains a challenge. Mutimodal anesthesia alleviates pain through blockade of multiple nociceptive and inflammatory pain receptors. MethodsA retrospective chart review of anesthetic and postoperative mangement of 125 children undergoing the Nuss procedure was conducted. Anesthetic mangement strategies were analyzed in four groups: opioid during general anesthesia (GA), epidural with general anesthesia (Epidural), multimodal anesthesia (MM), and multimodal anesthesia with methadone (MM+M). Data collection included total opioid use (as equivalent milligrams of morphine (Mmg)), pain scores, length of stay (LOS), and adverse effects. ResultsTotal opioid use varied by group (median, IQR (in Mg)): Epidural 213 [149, 293], GA 179 [134, 298], MM (150 [123, 281]), and MM+M (106 [87, 149]), as did severe pain (in minutes): Epidural (208 [73, 323]), GA (115 [7, 255]), MM (54 [0, 210]), and MM+M (49 [0, 151]). LOS was shortest for the MM+M group (MM+M=3.8+1.0days; MM=4.5+1.3days; GA=4.9+1.4days, Epidural=5.5+2.3days). ConclusionMultimodal anesthesia is associated with less postoperative pain and shorter LOS compared to epidural or traditional anesthetic techniques for the Nuss procedure. Multimodal anesthesia with a single intraoperative dose of methadone was associated with lowest total opioid use, time with uncontrolled pain, and shortest LOS.

Clinical benchmarks regarding multimodal peripheral nerve blocks for postoperative analgesia: observations regarding combined perineural midazolam-clonidine-buprenorphine-dexamethasone.

In a separate commentary [1], we reported on potential clinical research priorities with respect to multimodal perineural anesthesia and analgesia (MMPNA). This was based on our group's review of institutional quality assurance/improvement (QA/QI) data routinely using this technique for over 1,300 patients from late 2011 to the present at the Veterans Affairs Pittsburgh Healthcare System. This previous commentary addressed the four-drug combination of bupivacaine, clonidine, buprenorphine, and dexamethasone (BPV-CBD) used for postoperative perineural analgesia (e.g., combined with intraoperative spinal anesthesia), or for the dual role of intraoperative perineural anesthesia and postoperative analgesia. The average block duration (block insertion time until peak rebound pain score on a 0 to 10 scale) in this previous commentary was 33 to 37 hours, depending on the context. We believe that this clinical observation warrants high-priority research for the specialty, especially in the context of the effects of buprenorphine dose response and the parameters of block duration and rebound pain. In this current commentary, we will direct separate attention toward the four-drug combination of midazolam (MDZ) with CBD used for specific contexts of motor-sparing perineural analgesia. Both BPV-CBD and MDZ-CBD four-drug nerve block combinations were shown to be safe in vivo, as reported in a separate manuscript [2] in this issue of Pain Medicine . Based on the previously reported in vitro safety of MDZ-CBD [3], we used MDZ-CBD blocks in selected cases where the risk of motor block (and subsequent falls) was deemed as high as the potential short- and long-term risks of escalating systemic opioid analgesia (and/or intraoperative conversion to general endotracheal anesthesia [GETA]). All patients were fully informed before the use of MDZ-CBD as an “off-label” good-faith effort to 1) avoid motor block (i.e., routinely resulting from perineural bupivacaine use with or without perineural CBD use); 2) avoid GETA; and …

Local anaesthetic infiltration for peri-operative pain control in total hip and knee replacement: systematic review and meta-analyses of short- and long-term effectiveness

BackgroundSurgical pain is managed with multi-modal anaesthesia in total hip replacement (THR) and total knee replacement (TKR). It is unclear whether including local anaesthetic infiltration before wound closure provides additional pain control.MethodsWe performed a systematic review of randomised controlled trials of local anaesthetic infiltration in patients receiving THR or TKR. We searched MEDLINE, Embase and Cochrane CENTRAL to December 2012. Two reviewers screened abstracts, extracted data, and contacted authors for unpublished outcomes and data. Outcomes collected were post-operative pain at rest and during activity after 24 and 48 hours, opioid requirement, mobilisation, hospital stay and complications. When feasible, we estimated pooled treatment effects using random effects meta-analyses.ResultsIn 13 studies including 909 patients undergoing THR, patients receiving local anaesthetic infiltration experienced a greater reduction in pain at 24 hours at rest by standardised mean difference (SMD) -0.61 (95% CI -1.05, -0.16; p = 0.008) and by SMD -0.43 (95% CI -0.78 -0.09; p = 0.014) at 48 hours during activity.In TKR, diverse multi-modal regimens were reported. In 23 studies including 1439 patients undergoing TKR, local anaesthetic infiltration reduced pain on average by SMD -0.40 (95% CI -0.58, -0.22; p < 0.001) at 24 hours at rest and by SMD -0.27 (95% CI -0.50, -0.05; p = 0.018) at 48 hours during activity, compared with patients receiving no infiltration or placebo. There was evidence of a larger reduction in studies delivering additional local anaesthetic after wound closure. There was no evidence of pain control additional to that provided by femoral nerve block.Patients receiving local anaesthetic infiltration spent on average an estimated 0.83 (95% CI 1.54, 0.12; p = 0.022) and 0.87 (95% CI 1.62, 0.11; p = 0.025) fewer days in hospital after THR and TKR respectively, had reduced opioid consumption, earlier mobilisation, and lower incidence of vomiting.Few studies reported long-term outcomes.ConclusionsLocal anaesthetic infiltration is effective in reducing short-term pain and hospital stay in patients receiving THR and TKR. Studies should assess whether local anaesthetic infiltration can prevent long-term pain. Enhanced pain control with additional analgesia through a catheter should be weighed against a possible infection risk.

Bone marrow aspiration performed using multimodal local infiltration anaesthesia: a randomized double blind controlled study

1Karolinska Institute, Dept of Physiology and Pharmacology, Stockholm, Sweden, 2Karolinska Institute, Dept of Medicine, Stockholm, Sweden, 3Karolinska University Hospital Solna, Hematology Center, Stockholm, Sweden

Perioperative Multimodal Anesthesia Using Regional Techniques in the Aging Surgical Patient

Background. Elderly patients have unique age-related comorbidities that may lead to an increase in postoperative complications involving neurological, pulmonary, cardiac, and endocrine systems. There has been an increase in the number of elderly patients undergoing surgery as this portion of the population is increasing in numbers. Despite advances in perioperative anesthesia and analgesia along with improved delivery systems, monotherapy with opioids continues to be the mainstay for treatment of postop pain. Reliance on only opioids can oftentimes lead to inadequate pain control or increase in the incidence of adverse events. Multimodal analgesia incorporating regional anesthesia is a promising alternative that may reduce needs for high doses and dependence on opioids along with any potential associated adverse effects. Methods. The following databases were searched for relevant published trials: Cochrane Central Register of Controlled Trials and PubMed. Textbooks and meeting supplements were also utilized. The authors assessed trial quality and extracted data. Conclusions. Multimodal drug therapy and perioperative regional techniques can be very effective to perioperative pain management in the elderly. Regional anesthesia as part of multimodal perioperative treatment can often reduce postoperative neurological, pulmonary, cardiac, and endocrine complications. Regional anesthesia/analgesia has not been proven to improve long-term morbidity but does benefit immediate postoperative pain control. In addition, multimodal drug therapy utilizes a variety of nonopioid analgesic medications in order to minimize dosages and adverse effects from opioids while maximizing analgesic effect and benefit.

The Influence of Anesthesia and Pain Management on Cognitive Dysfunction After Joint Arthroplasty: A Systematic Review

Despite the overall success of total joint arthroplasty, patients undergoing this procedure remain susceptible to cognitive decline and/or delirium, collectively termed postoperative cognitive dysfunction. However, no consensus exists as to whether general or regional anesthesia results in a lower likelihood that a patient may experience this complication, and controversy surrounds the role of pain management strategies to minimize the incidence of postoperative cognitive dysfunction. We systematically reviewed the English-language literature to assess the influence of the following anesthetic and/or pain management strategies on the risk for postoperative cognitive dysfunction in patients undergoing elective joint arthroplasty: (1) general versus regional anesthesia, (2) different parenteral, neuraxial, or inhaled agents within a given type of anesthetic (general or regional), (3) multimodal anesthetic techniques, and (4) different postoperative pain management regimens. A systematic search was performed of the MEDLINE(®) and EMBASE™ databases to identify all studies that assessed the influence of anesthetic and/or pain management strategies on the risk for postoperative cognitive dysfunction after elective joint arthroplasty. Twenty-eight studies were included in the final review, of which 21 (75%) were randomized controlled (Level I) trials, two (7%) were prospective comparative (Level II) studies, two (7%) used a case-control (Level III) design, and three (11%) used retrospective comparative (Level III) methodology. The evidence published to date suggests that general anesthesia may be associated with increased risk of early postoperative cognitive dysfunction in the early postoperative period as compared to regional anesthesia, although this effect was not seen beyond 7days. Optimization of depth of general anesthesia with comprehensive intraoperative cerebral monitoring may be beneficial, although evidence is equivocal. Multimodal anesthesia protocols have not been definitively demonstrated to reduce the incidence of postoperative cognitive dysfunction. Nonopioid postoperative pain management techniques, limiting narcotics to oral formulations and avoiding morphine, appear to reduce the risk of postoperative cognitive dysfunction. Both anesthetic and pain management strategies appear to influence the risk of early cognitive dysfunction after elective joint arthroplasty, although only one study identified differences that persisted beyond 1week after surgery. Investigators should strive to use accepted, validated tools for the assessment of postoperative cognitive dysfunction and to carefully report details of the anesthetic and analgesic techniques used in future studies.