The Effect of Neuraxial Versus General Anesthesia Techniques on Postoperative Quality of Recovery and Analgesia After Abdominal Hysterectomy: A Prospective, Randomized, Controlled Trial [Comparative study of general and spinal anesthesia in elderly women in hip surgery]. [The effect of anesthesiologic technique on the mental state of elderly patients submitted for orthopedic surgery of the lower limbs]. Cardiac Outcome after Peripheral Vascular Surgery: Comparison of General and Regional Anesthesia Effect of informational internet web pages on patients’ decision‐making: randomised controlled trial regarding choice of spinal or general anaesthesia for orthopaedic surgery Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of Interventional Management of Stroke (IMS) III Trial Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition) Impact of Anesthesia on Mortality During Endovascular Clot Removal for Acute Ischemic Stroke A Prospective Randomised Trial Comparing Spinal Anaesthesia using Hyperbaric Cinchocaine with General Anaesthesia for Lower Limb Vascular Surgery Comparison of the effects of spinal anaesthesia and general anaesthesia on postoperative oxygenation and perioperative mortality. Spinal anesthesia versus general anesthesia for elective lumbar spine surgery: A randomized clinical trial Neuroleptanesthesia versus thoracic epidural anesthesia for abdominal aortic surgery. Anesthetic Management and One-Year Mortality After Noncardiac Surgery Combined epidural and general anesthesia versus general anesthesia for abdominal aortic surgery. Postoperative Confusion after Anesthesia in Elderly Patients with Femoral Neck Fractures
BACKGROUND : Patients undergoing abdominal hysterectomy often have significant postoperative pain despite the use of concurrent multimodal pain strategies . Neuraxial anesthesia has opioid-sparing effects and may provide better postoperative recovery to patients when compared with general anesthesia . Our main objective in this study was to compare the effects of neuraxial and general anesthesia on postoperative quality of recovery after abdominal hysterectomy . METHODS : The study was a prospect i ve , r and omized , controlled clinical trial . Seventy healthy females were recruited and r and omized to a general anesthesia or neuraxial technique  as their primary anesthetic regimen . The primary outcome was the global quality of recovery—40 question naire ( QoR–40 ) at 24 hours after the surgical procedure . Other data collected included postoperative pain scores and opioid consumption . Data were analyzed using the Mann – Whitney U test , Fisher 's exact test , and linear regression . A P value < 0.05 was considered statistically significant . RESULTS : The median difference ( 95 % confidence interval [ CI ] ) in the global QoR–40 score at 24 hours between the neuraxial and general anesthesia groups was 17 ( 11 to 21.5 ) ( P < 0.001 ) . Patients in the neuraxial anesthesia group had better quality of recovery scores in all the QoR–40 subcomponents than did the general anesthesia group ( all P < 0.005 ) . The median difference in global QoR–40 scores at 48 hours between the neuraxial anesthesia and the general anesthesia groups was 8 ( 6–10 ) ( P < 0.001 ) . Postoperative opioid consumption and pain scores were higher in the general anesthesia group than in the neuraxial anesthesia group . There was an inverse linear relationship between opioid consumption and postoperative quality of recovery at 24 hours , r 2 = 0.67 ( P < 0.0001 , 95 % CI of 0.77 to 0.51 ) , and at 48 hours , r 2 = 0.58 ( P < 0.0001 , 95 % CI of 0.72 to 0.42 ) . CONCLUSION : Neuraxial anesthesia provides better quality of recovery than does general anesthesia for patients undergoing abdominal hysterectomy . The opioid-sparing effects of neuraxial anesthesia were associated with a better quality of recovery in patients after the surgical procedure . In the absence of contraindications , neuraxial anesthesia seems to be a better anesthetic plan for those patients The choice between regional versus general anaesthesia for elderly patients undergoing hip surgery is debated . It is vitally important to see if the type of anaesthetic administered affects per- and postoperative morbidity and mortality .  Seventy women more than 75 yr old suitable for spinal anaesthesia were included in this study . They were r and omly divided into two groups : in one ( n = 35 ) , general anaesthesia was given with sodium thiopentone , fentanyl , enflurane and vecuronium ; in the other ( n = 35 ) , spinal anaesthesia was performed with 3 ml 0.5 % bupivacaine in isobaric solution . During the anaesthetic period , there were no statistically significant differences between both groups in systolic arterial pressure falls or in increases in the heart rate X systolic arterial pressure product . No serious cardiovascular collapse was encountered . Seven patients ( 20 % ) receiving general anaesthesia had mental changes against four only ( 14.2 % ) in the spinal group . In patients having general anaesthesia , 22.9 % developed bronchopneumonia as opposed to 8.6 % in the spinal anaesthesia group ( p less than 0.05 ) . The mortality rate at three months was rather similar in the two groups . It was concluded that , in order to reduce the incidence of postoperative central dysfunction and bronchopneumonia , spinal anaesthesia should be preferred in geriatric patients for lower limb surgery UNLABELLED Influence of anesthetic technique on mental status in elderly patients su bmi tted to major orthopedic procedures of lower limbs . Mental impairment is a common occurrence in elderly patients after major orthopedic surgery . Few studies have been published so far on this topic in spite of its relevant clinical and economic implication s. OBJECTIVE 1 ) To verify whether anesthesia has a causative role in postoperative mental confusion in elderly patients ; 2 ) to compare the effects of General Anesthesia ( GA ) and Spinal Anesthesia ( SA ) on mental status . DESIGN Controlled , comparative study . PATIENTS Sixty patients aged > or = 70 , ASA I-II , su bmi tted to femoral neck repair . SETTING Anesthesia Dept . and Orthopedic Dept . of a District Hospital in Italy . METHOD The day before surgery the mental status of elected patients was evaluated employing a modified Organic Brain Syndrome ( OBS ) scale ( Gustafsson ) . The better the mental status , the lesser the OBS score . It was possible therefore to distinguish " oriented " from " confuse " patients ( 38 vs 22 ) if they scored < or = 6 or > 6 respectively . Patients from each group were than r and omly assigned to receive either GA or selective SA . Neither group was premedicated . GA was induced with propofol 1 mg/kg and maintained with O2/N2O 40/60 % and isoflurane ; atracurium was employed to facilitate mioresolution . Spinal anesthesia was performed with hyperbaric 1 % bupivacaine . All patients were monitored in the Recovery Room ( RR ) for at least one hour . Occurrence of hypotension and /or hypoxia in the Operating Room ( OR ) or the RR was immediately treated . Mental status was reassessed on the 1st and 2nd postoperative day and results were compared with the corresponding preoperative OBS scores both in GA patients and in SA patients . RESULTS No statistically significant differences were found between pre- and postoperative OBS scores in both GA and SA group , whether " oriented " or " confuse " . CONCLUSIONS Mental status of elderly patients su bmi tted to femoral neck repair does n't seem to be influenced by the anesthetic technique chosen , independent of preoperative psychic conditions Background Despite evidence that regional anesthesia may be associated with fewer perioperative complications than general anesthesia , most studies that have compared cardiac outcome after general or regional anesthesia alone have not shown major differences . This study examines the impact of anesthetic choice on cardiac outcome in patients undergoing peripheral vascular surgery who have a high likelihood of associated coronary artery disease . Methods Four hundred twenty‐three patients , between 1988 and 1991 , were r and omly assigned to receive general ( n = 138 ) , epidural ( n = 149 ) , or spinal anesthesia ( n = 136 ) for femoral to distal artery bypass surgery . All patients were monitored with radial artery and pulmonary artery catheters . Postoperatively , patients were in a monitored setting for 48–72 h and had daily electrocardiograms for 4–5 days and creatine phosphokinase/isoenzymes every 8 h x 3 , then daily for 4 days . Cardiac outcomes recorded were myocardial infa rct ion , angina , and congestive heart failure . Results Baseline clinical characteristics were not different between anesthetic groups . Overall , the patient population included 86 % who were diabetic , 69 % with hypertension , 36 % with a history of a prior myocardial infa rct ion , and 41 % with a history of smoking . Cardiovascular morbidity and overall mortality were not significantly different between groups when analyzed by either intention to treat or type of anesthesia received . In the intention to treat analysis , incidences of cardiac event or death for general , spinal , and epidural groups were 16.7 % , 21.3 % , and 15.4 % , respectively . The absolute risk difference observed between general and all regional anesthesia groups for cardiac event or death was ‐1.6 % ( 95 % confidence interval ‐9.2 % , 6.1 % ) This reflected a nonsignificant trend for lower risk of postoperative events with general anesthesia . Conclusions The choice of anesthesia , when delivered as described , does not significantly influence cardiac morbidity and overall mortality in patients undergoing peripheral vascular surgery This study explored whether patients ’ preference for particular types of anaesthesia  could be influenced pre‐operatively by giving them the addresses of various relevant websites . Patients at an orthopaedic pre‐ assessment education clinic completed a question naire , which included a short multiple‐choice general knowledge quiz about anaesthesia , and also question ed them as to their choice of anaesthesia ( general or neuraxial ) . Patients were r and omly assigned to intervention or control groups . Intervention group members were given the addresses of three relevant anaesthesia and health related websites to access at home . All patients were asked to complete the question naires on a second occasion , before surgery . Initially , most patients stated a preference for general anaesthesia . Subsequently , the intervention group altered their preference towards neuraxial anaesthesia compared to the control group ( p ≤ 0.0001 ) . The increase in median ( IQR [ range ] ) anaesthesia knowledge test score was greater in the intervention group ( from 10.0 ( 9.0–12.0 [ 5.0–14.0 ] ) to 13.0 ( 11.0–14.0 [ 6.0–14.0 ] ) ) than in the control group ( from 10.0 ( 9.0–11.5 [ 3.0–13.0 ] ) to 11.0 ( 9.0–12.0 [ 4.0–14.0 ] ) ; p = 0.0068 ) In a prospect i ve r and omized multi-centre study , the mortality following internal fixation surgery for fracture of the upper femur was investigated in 538 elderly patients allocated to receive subarachnoid blockade or general ( narcotic-relaxant ) anaesthesia .  The 28-day mortality was 6.6 % with subarachnoid , and 5.9 % with general , anaesthesia . The difference was not significant ( 95 % confidence limits : -3.5 to + 4.8 ) . At 1 year following surgery , the mortality was 20.4 % . Increasing age , ischaemic heart disease , cardiac failure , preoperative arrhythmias and poor ASA status were all associated with increases in early and long term mortality . A delay to surgery of more than 24 h from admission was also associated with an increased 28-day mortality . Senile dementia and admission other than from the patient 's own home , were factors associated with a poorer long term outcome . From the point of view of mortality , subarachnoid anaesthesia did not appear to confer any advantages over general anaesthesia in non-prosthetic surgery for hip fracture in the elderly Background and Purpose — General anesthesia ( GA ) for endovascular therapy ( EVT ) of acute ischemic stroke may be associated with worse outcomes . Methods — The Interventional Management of Stroke III trial r and omized patients within 3 hours of acute ischemic stroke onset to intravenous tissue-type plasminogen activator±EVT . GA use within 7 hours of stroke onset was recorded per protocol . Good outcome was defined as 90-day modified Rankin Scale ⩽2 . A multivariable analysis adjusting for dichotomized National Institutes of Health Stroke Scale ( NIHSS ; 8–19 versus ≥20 ) , age , and time from onset to groin puncture was performed . Results — Four hundred thirty-four patients were r and omized to EVT , 269 ( 62 % ) were treated under local anesthesia and 147 ( 33.9 % ) under GA ; 18 ( 4 % ) were undetermined . The 2 groups were comparable except for median baseline NIHSS ( 16 local anesthesia versus 18 GA ; P<0.0001 ) . The GA group was less likely to achieve a good outcome ( adjusted relative risk , 0.68 ; confidence interval , 0.52–0.90 ; P=0.0056 ) and had increased in-hospital mortality ( adjusted relative risk , 2.84 ; confidence interval , 1.65–4.91 ; P=0.0002 ) . Those with medically indicated GA had worse outcomes ( adjusted relative risk , 0.49 ; confidence interval , 0.30–0.81 ; P=0.005 ) and increased mortality ( relative risk , 3.93 ; confidence interval , 2.18–7.10 ; P<0.0001 ) with a trend for higher mortality with routine GA . There was no significant difference in the adjusted risks of subarachnoid hemorrhage ( P=0.32 ) or symptomatic intracerebral hemorrhage ( P=0.37 ) . Conclusions — GA was associated with worse neurological outcomes and increased mortality in the EVT arm ; this was primarily true among patients with medical indications for GA . Relative risk estimates , though not statistically significant , suggest reduced risk for subarachnoid hemorrhage and symptomatic intracerebral hemorrhage under local anesthesia . Although the reasons for these associations are not clear , these data support the use of local anesthesia when possible during EVT . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00359424 Abstract Objectives : To determine whether preoperative optimisation of oxygen delivery improves outcome after major elective surgery , and to determine whether the inotropes , adrenaline and dopexamine , used to enhance oxygen delivery influence outcome . Design : R and omised controlled trial with double blinding between inotrope groups . Setting : York District Hospital , Engl and . Subjects:138 patients undergoing major elective surgery who were at risk of developing postoperative complications either because of the surgery or the presence of coexistent medical conditions . Interventions : Patients were r and omised into three groups . Two groups received invasive haemodynamic monitoring , fluid and either adrenaline or dopexamine to increase oxygen delivery . Inotropic support was continued during surgery and for at least12 hours afterwards . The third group ( control ) received routine perioperative care . Main outcome measures : Hospital mortality and morbidity . Results : Overall , 3/92 ( 3 % ) preoptimised patients died compared with 8/46 controls ( 17 % ) ( P=0.007 ) . There were no differences in mortality between the treatment groups , but 14/46 ( 30 % ) patients in the dopexamine group developed complications compared with 24/46 ( 52 % ) patients in the adrenaline group ( difference 22 % , 95%confidence interval 2 % to 41 % ) and 28 patients ( 61 % ) in the control group ( 31 % , 11 % to 50 % ) . The use of dopexamine was associated with a decreased length of stay in hospital . Conclusion : Routine preoperative optimisation of patients undergoing major elective surgery would be a significant and cost effective improvement in perioperative care The actual incidence of neurologic dysfunction result ing from hemorrhagic complications associated with neuraxial blockade is unknown . Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics , recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient population s. Overall , the risk of clinical ly significant bleeding increase with age , associated abnormalities of the spinal cord or vertebral column , the presence of an underlying coagulopathy , difficulty during needle placement , and an indwelling neuraxial catheter during sustained anticoagulation ( particularly with st and ard heparin or low-molecular weight heparin ) . The need for prompt diagnosis and intervention to optimize is also consistently reported . In response to these patient safety issues , the American Society of Regional Anesthesia and Pain Medicine ( ASRA ) convened its Third Consensus Conference on Regional Anesthesia and Anticoagulation . Practice guidelines or recommendations summarize evidence -based review s. However , the rarity of spinal hematoma defies a prospect i ve r and omized study , and there is no current laboratory model . As a result , the ASRA consensus statements represent the collective experience of recognized experts in the field of neuraxial anesthesia and anticoagulation . These are based on case reports , clinical series , pharmacology , hematology , and risk factors for surgical bleeding . An underst and ing of the complexity of this issue is essential to patient management Background : Endovascular clot retrieval is a technique available for removing intracranial arterial occlusions in acute ischemic stroke ( AIS ) . This rescue therapy can be performed with moderate conscious sedation ( CS ) or general anesthesia ( GA ) . The effect of GA on clinical outcome in AIS remains controversial . Therefore , we retrospectively investigated whether the use of CS or GA during endovascular intervention for AIS influenced outcomes . Methods : Patients who underwent emergent endovascular intervention for intracranial arterial occlusion during the years 2006 to 2012 were included in this study . Statistical analysis using the Spearman & rgr ; was performed to examine demographic data and clinical outcomes between patients in the GA and CS groups . Binary logistic regression was used to determine the predictors of mortality . Results : A total of 109 patients fit the inclusion criteria . Among them , 35 patients had GA and 74 patients had CS . Patients needing intubation upon admission for airway protection were more likely to receive GA ( P<0.001 ) . The duration of the procedure and the time-to-revascularization from symptom onset were significantly longer in the GA group . Mortality was higher in the  GA  group compared with the CS group ( 40 % vs. 22 % , P=0.045 ) . Multivariate analysis , controlled for confounding variables , identified GA and elevated postprocedure glucose level to be significant predictors of mortality . Conclusions : Larger prospect ively r and omized multicenter trials evaluating the effects of GA and CS on clinical and radiographic outcomes seems warranted One hundred and one patients were r and omly allocated to have their peripheral vascular surgery performed under general anaesthesia ( 51 patients ) or spinal anaesthesia ( 50 patients ) .  Intraoperative haemodynamic changes were markedly different between the two groups with a higher incidence of hypotension in the spinal group ( 72 % vs 31 % ) and a higher incidence of hypertension in the general anaesthesia group ( 22 % vs 0 % ) . Blood loss was significantly less in the spinal group ( 560 , SD 340 , ml vs 792 , SD 440 , ml ) . Postoperatively three patients from the general anaesthesia group died from causes unrelated to the anaesthesia , and one had a myocardial infa rct . Two patients in the spinal group had myocardial infa rcts , both had been treated for bradycardia and hypotension intraoperatively , and one died . There was a significantly higher incidence of postoperative chest infection in the general anaesthesia group ( 33 % vs 16 % ) . There was no significant difference between the groups in the incidence of postoperative confusion , or lower limb amputation rate or need for further surgery prior to hospital discharge One hundred patients presenting for surgical treatment of fractured neck of femur were allocated to receive either spinal ( SAB ) or general ( GA ) anaesthesia . Before operation , the mean PaO2 was 9.04 kPa . There was a significant decrease in PaO2 of 0.68 kPa in GA group at 1 h after operation , while blood-gas values were unchanged in SAB group . Eight patients ( 15.7 % ) in GA group and five patients ( 10.2 % ) in SAB group died within 4 weeks of surgery . The difference was not statistically significant BACKGROUND : Either general or regional anesthesia can be used for lumbar disk surgery . The common anesthetic technique is general anesthesia ( GA ) . The aim of this study was to compare the intra and postoperative outcomes of spinal anesthesia ( SA ) with GA in these patients . METHODS : Seventy-two patients were enrolled in the study . They were r and omized into two groups with 37 patients in GA Group and 35 ones in SA Group . The heart rate ( HR ) , mean arterial pressure ( MAP ) , blood loss , surgeons satisfaction with the operating conditions , the severity of postoperative pain based on visual analogue scale ( VAS ) and analgesic use were recorded . RESULTS : The mean blood loss was significantly less in the SA Group compared to GA Group ( p < 0.05 ) . Intraoperative maximum blood pressure and heart rate changes were significantly less in SA Group ( p < 0.05 ) . The surgeons satisfaction was significantly more in the SA Group ( p < 0.05 ) . The number of patients who used postoperative analgesic as well as postoperative mean VAS was significantly less in SA Group in comparison with GA group ( p < 0.05 for both ) . CONCLUSIONS : Our study showed that SA was superior to GA in providing postoperative analgesia and decreasing blood loss while maintained better perioperative hemodynamic stability without increasing adverse side effects The hemodynamic consequences of abdominal aortic surgery with infrarenal cross-clamping were studied in 21 patients r and omized in two groups . In Group I ( 11 patients ) , neuroleptanesthesia was utilized , while Group II ( 10 patients ) received thoracic epidural anesthesia at the T8 - 9 level . Hemodynamic measurements were performed using Swan-Ganz catheters during the surgical procedures in all patients , with special attention to the periods of clamping and unclamping of the abdominal aorta . The thoracic epidural anesthesia group was characterized by greater hemodynamic stability during surgery , while patients in the neuroleptanesthesia group had significant lability of blood pressure , heart rate , and cardiac index . Nevertheless , in the two groups of patients , it is suggested that cardiac function was unfitted to the tissue oxygen dem and after unclamping of the aortic prosthesis because the saturation in oxygen of the mixed venous blood and an increase in arteriovenous difference in oxygen were documented . These results point out that , whatever the anesthesia technique , the critical period in abdominal surgery could be aortic unclamping Little is known about the effect of anesthetic management on long-term outcomes . We design ed a prospect i ve observational study of adult patients undergoing major noncardiac surgery with general anesthesia  to determine if mortality in the first year after surgery is associated with demographic , preoperative clinical , surgical , or intraoperative variables .  One-year mortality was 5.5 % in all patients ( n = 1064 ) and 10.3 % in patients ≥65 yr old ( n = 243 ) . Multivariate Cox Proportional Hazards modeling identified three variables as significant independent predictors of mortality : patient comorbidity ( relative risk , 16.116 ; P < 0.0001 ) , cumulative deep hypnotic time ( Bispectral Index ® < 45 ) ( relative risk = 1.244/h ; P = 0.0121 ) and intraoperative systolic hypotension ( relative risk = 1.036/min ; P = 0.0125 ) . Death during the first year after surgery is primarily associated with the natural history of preexisting conditions . However , cumulative deep hypnotic time and intraoperative hypotension were also significant , independent predictors of increased mortality . These associations suggest that intraoperative anesthetic management may affect outcomes over longer time periods than previously appreciated The goal of this r and omized study of high-risk surgical patients was to determine whether intraoperative thoracic epidural anesthesia in combination with light general anesthesia alters postoperative morbidity when compared to a st and ard technique of " balanced " general anesthesia . A total of 173 patients scheduled for abdominal aortic reconstruction were admitted to the study ; 86 were to receive " balanced " general anesthesia ( group 1 ) and 87 thoracic epidural anesthesia in combination with light general anesthesia ( group 2 ) . Preoperative evaluation included  st and ard clinical tools , dipyridamole thallium gammatomography , and radionuclide angiography .  In these patients , all of whom had peripheral artery disease , there were no significant differences in associated  coronary artery disease , hypertension , and cardiovascular treatment . The distribution of left ventricular ejection fraction and the number of patients with thallium redistribution were not statistically different between the two groups . During the postoperative period , group 1 received analgesia of subcutaneous morphine ( n = 35 ) , epidural fentanyl ( n = 30 ) , or epidural bupivacaine ( n = 21 ) . In group 2 , 6 patients with a nonfunctioning epidural catheter due to technical failure received a balanced general anesthesia and were eliminated from the study . During the postoperative period , group 2 received analgesia of subcutaneous morphine ( n = 26 ) , epidural fentanyl ( n = 25 ) , or epidural bupivacaine ( n = 30 ) . Cardiovascular morbidity did not differ between the two groups : 22 patients in group 1 and 19 patients in group 2 had a major postoperative cardiac event . ( ABSTRACT TRUNCATED AT 250 WORDS Fifty-seven patients , all over the age of 64 , with femoral neck fracture were r and omized to receive epidural or halothane anesthesia  to see if the anesthetic technique influenced the incidence of postoperative confusion . All patients were lucid on admission . Using the American Psychiatric Association 's Diagnostic and Statistical Manual of Mental Disorders ( DSM-III ) as criteria for confusion , we found that 44 % of the patients developed confusion that correlated closely to a history of mental depression ( P < 0.01 ) and to the use of drugs with anticholinergic effect ( P < 0.005 ) . There was no difference in the incidence of confusion between the two anesthetic groups . In patients given halothane , however , early postoperative hypoxemia was associated with confusion ( P < 0.05 ) . Patients with confusion had significantly more postoperative complications and almost four times longer hospitalization times . It is concluded that anticholinergic medication and a history of mental depression are predominant risk factors for development of postoperative confusion and in this respect are more important than the anesthetic technique
So far , the evidence available from the studies included is insufficient to prove that neuraxial anesthesia is more effective and safer than general anesthesia for orthopedic surgery .
However , this systematic review does not rule out clinical ly important differences with regard to mortality , stroke , myocardial infa rct ion , length of hospitalization , postoperative cognitive dysfunction or pneumonia
CONTEXT AND OBJECTIVE Taking the outcome of mortality into consideration , there is controversy about the beneficial effects of neuraxial anesthesia for orthopedic surgery .
The aim of this study was to compare the effectiveness and safety of neuraxial anesthesia versus general anesthesia for  orthopedic surgery .