Anesthetic techniques during surgical repair of femoral neck fractures. A meta-analysis

Association of Duration of Surgery With Postoperative Delirium Among Patients Receiving Hip Fracture Repair

IMPORTANCE

Postoperative delirium in older adults receiving hip fracture surgery is associated with morbidity and increased health care costs, yet little is known of potential modifiable factors that may help limit the risks.

OBJECTIVE

To use population-wide individual-level data on the duration of hip fracture surgery to determine whether prolonged surgical times and type of anesthesia are associated with an increased risk of postoperative delirium.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study analyzed patients aged 65 years and older receiving hip fracture surgery between April 1, 2009, and March 30, 2017, at 80 hospitals in Ontario, Canada. Generalized estimated equations with logistic regression analysis were used to determine the relationship between procedure duration, type of anesthesia, and the occurrence of postoperative delirium. Restricted cubic splines were also generated to visualize this relationship. Data analysis was conducted from July to October 2018, revision in January 2019.

EXPOSURE

Surgery duration, measured as the total time in the operating room.

MAIN OUTCOMES AND MEASURES

A diagnosis of postoperative delirium during hospitalization.

RESULTS

Among 68 131 patients with surgically managed hip fracture (median [interquartile range] age, 84 [78-89] years; 72% women) identified, 7150 patients experienced postoperative delirium. In total, 26 853 patients (39.4%) received general anesthesia. Receiving general anesthesia was associated with a slightly higher rate of postoperative delirium compared with not receiving general anesthesia (2943 [11.0%] vs 4207 [10.2%]; P = .001). The risk for delirium increased with increased surgical duration-every 30-minute increase in the duration of surgery was associated with a 6% increase in the risk for delirium (adjusted odds ratio, 1.06; 95% CI, 1.03-1.08; P < .001). Prolonged surgical duration was associated with a higher incidence of postoperative delirium, and the risk was higher was in patients who had received general anesthesia (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; P < .001) than in those patients who did not receive GA (adjusted odds ratio, 1.04; 95% CI, 1.01-1.08; P = .01).

CONCLUSIONS AND RELEVANCE

Among older adults receiving hip fracture surgery, both an increased duration of surgery and receiving a general anesthetic were associated with an increased risk for postoperative delirium.

The efficiency of suction drain usage in arthroscopic knee surgery

Aim: The study was designed to investigate the efficiency of suction drain after arthroscopic knee surgery. It is hypothesized that suction drain decreases postoperative hemarthrosis after arthroscopic knee surgery. Methods: Patients were randomized into two groups. Suction drain was used in Group I and no drain was used in Group II. The groups were compared in terms of rest and activity pain, range of motion, Lysholm and International Knee Documentation Committee (IKDC) scores, patellar shock, need for postoperative knee puncture, amount of drainage, time of hospitalization, and loss of labor. Arthroscopic interventions like meniscectomy, synovectomy, meniscus repair and microfracture were also compared for the amount of patellar shock, need for postoperative knee puncture and amount of drainage. Results: The difference for activity pain and range of motion between the two groups was statistically nonsignificant. Rest pain improved faster in control group. Lysholm and IKDC scores were improved in both groups but the amount of increase was statistically nonsignificant. The amount of patellar shock was also statistically nonsignificant between the two groups. The amount of patellar shock, need for postoperative knee puncture and amount of drainage were also statistically nonsignifiant for arthroscopic interventions like meniscectomy and synovectomy. Conclusions: Suction drain application was unnecessary in many situations after arthroscopic knee surgery in this study. Although suction drain usage delayed the recovery from postoperative pain in this study, other parameters of pain were not affected from suction drain usage. Routine usage of a suction drain after arthroscopic knee surgery was not recommended.

Hip fracture surgery: does type of anesthesia matter?

BACKGROUND

Hip fracture surgery is a common procedure, and the geriatric population with its multiple comorbid conditions is at most at risk of developing anesthesia-related complications. Data on the impact of type anesthesia on postoperative morbidity and mortality is limited. The effects of regional and general anesthesia on postoperative outcomes need to be clearly elucidated.

METHODS

In this study, all patients who underwent dynamic hip screw (DHS) fixation for intertrochanteric fractures, between January 2005 and December 2010, at the Aga Khan University Hospital, were included. Patients were divided into two groups; group A included those patients who received general anesthesia, and group B consisted of patients who had received regional anesthesia. The two groups were compared for differences in morbidity, mortality, and intraoperative complications based on the type of anesthesia administered.

RESULTS

During this period, 194 patients underwent DHS fixation. One hundred and seven patients received general anesthesia whereas eighty-seven patients received regional anesthesia. The mean operative time was significantly lower in the group receiving regional anesthesia (1.25 ± 0.39 hrs) as compared to those who received general anesthesia (1.54 ± 0.6 hrs) (P < 0.05). There were no statistically significant differences in the rates of wound infections, length of hospital stay, postoperative ambulation status, intraoperative blood loss, postoperative complications, and mortality between the regional and general anesthesia groups.

CONCLUSION

Even though administration of regional anesthesia was positively correlated with shorter operative duration, the type of anesthesia was not found to affect surgical outcomes in the two study groups. Based on these results, we recommend that anesthesia should be tailored to individual patient requirements.

Type of anaesthesia and the safety and efficacy of thromboprophylaxis with enoxaparin or dabigatran etexilate in major orthopaedic surgery: pooled analysis of three randomized controlled trials

Background

There has been a shift towards greater use of neuraxial over general anaesthesia for patients undergoing total hip or knee arthroplasty. Furthermore, suggestions that peripheral nerve block may reduce adverse effects have recently been put forward. Although older studies showed a reduction in venous thromboembolism (VTE) with neuraxial compared with general anaesthesia, this difference has not been confirmed in studies using effective current thromboprophylaxis. We used a large data set to investigate the pattern of anaesthesia usage, and whether anaesthesia type affects efficacy and bleeding outcomes of thromboprophylaxis overall, within each treatment group, or for the novel oral anticoagulant dabigatran etexilate versus enoxaparin.

Methods

Three previously reported trials compared 220 mg and 150 mg dabigatran etexilate once daily with enoxaparin after knee or hip arthroplasty. A pooled analysis was performed in patients receiving general or neuraxial anaesthesia, or the combination of either with peripheral nerve block (n = 8062). Outcome measures were major VTE plus VTE-related mortality, major bleeding and major plus clinically relevant bleeding events.

Results

General, neuraxial and combination anaesthesia were used in 29%, 52% and 19% of patients, respectively. Differences in efficacy and safety between anaesthesia subgroups were small and not significant, except for a slightly higher rate of major VTE and VTE-related mortality with general versus neuraxial anaesthesia (odds ratio: 1.40; 95% confidence interval: 1.03–1.90; p = 0.035) in the overall population. There were no significant effects of anaesthesia type on efficacy or safety of dabigatran etexilate versus enoxaparin.

Conclusions

Anaesthesia type did not greatly affect efficacy and safety outcomes in the pooled population of all three treatment groups. The efficacy and safety of dabigatran etexilate was comparable with enoxaparin, regardless of type of anaesthesia.

Trial registration

ClinicalTrials.gov identifiers: NCT00168805, NCT00168818, NCT00152971.

Combination of high-dose dexmedetomidine sedation and fascia iliaca compartment block for hip fracture surgery

Two patients with hip fracture and with severe cardiac disease, who were anesthetized using a combination of dexmedetomidine sedation and fascia iliaca compartment block, are reported. The block covered almost the entire skin incision area and the major area of the fractured bone. The hemodynamic status and respiratory condition of both patients were stable throughout the surgery.

Venous thromboembolic prophylaxis for hip fractures

Patients with hip fractures are at very high risk for the development of venous thromboembolism (VTE). To provide an overview of cause, risk factors, current treatment strategies, and complications associated with VTE prophylaxis, we reviewed the most current, best available evidence on VTE prophylaxis for patients with hip fractures. We comprehensively reviewed the literature to assess the efficacy of VTE prophylaxis in patients with hip fractures, including the most recent published guidelines by national medical and surgical health organizations from the UK, USA, and Canada. Mechanical devices are effective in reducing the risk of VTE for hip fracture, but poor patient compliance is common and the devices are not recommended for sole VTE prophylaxis. Aspirin reduces the risk of VTE but does not provide optimal protection compared with other chemical agents; therefore, it is not recommended for sole VTE prophylaxis. Fondaparinux, warfarin, low-molecular-weight heparin, and unfractionated heparin reduce the risk of venographic deep vein thrombosis, but there is insufficient evidence that they reduce fatal pulmonary embolism or all-cause mortality. Fondaparinux is considered to be cost effective and more efficacious than low-molecular-weight heparin. At present, most major health organizations advocate at least 28 days of postoperative chemical prophylaxis. Chemical VTE prophylaxis should be administered to all patients with hip fractures unless contraindicated. Additional research is required to establish an agent that has a significant impact on fatal pulmonary embolism and all-cause mortality, without increasing bleeding complications, in this group of patients.

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

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

The impact of open reduction internal fixation on acute pain management in unstable pelvic ring injuries

BACKGROUND

The management of unstable pelvic ring injuries is complex. Displacement is a clear indication for surgical intervention. However, reduction of acute pain after stabilization may have substantial clinical benefits and affect management decisions. The purpose of this study was to determine the impact of operative fixation of unstable pelvic ring injuries in diminishing acute pain.

METHODS

During a 33-month period, 70 patients with isolated pelvic ring injuries were managed at a Level-1 trauma center and retrospectively reviewed. On the basis of clinical and radiographic instability, 38 patients were managed surgically and formed the study group. Pain was assessed using visual analog scales and narcotic consumption during the index hospitalization.

RESULTS

In the operative group, visual analog scale scores decreased 48% after fixation from 4.71 +/- 1.8 preoperatively to 2.85 +/- 0.8 postoperatively (p < 0.001). Concomitantly, narcotic requirements decreased 25% from 2.26 mg morphine per hour preoperatively to 1.71 mg morphine per hour postoperatively (p = 0.024). The mean total length of hospital stay was 5.6 days (SD, 1.2 days), and the postoperative length of hospital stay was 4.7 days (SD, 1.2 days).

CONCLUSIONS

Operative reduction and fixation of unstable pelvic ring injuries significantly decreases acute pain. This has substantial physiologic benefits, particularly by improving mobilization, and should be an additional factor when determining surgical indication and timing.

Femoral nerve block versus fentanyl: Analgesia for positioning patients with fractured femur

Purpose

Fracture of femur is a painful bone injury, worsened by any movement. This prospective study was performed to compare the analgesic effects of femoral nerve block (FNB) with intravenous (IV) fentanyl prior to positioning patients with fractured femur for spinal block.

Patients and methods

Sixty-four ASA I–III patients aged 18–80 years undergoing surgery for femur fracture were randomized into two groups. Fifteen minutes before spinal block, the FNB group received nerve stimulator-assisted FNB with a mixture of 20 mL bupivacaine 0.5% and 10 mL normal saline 0.9%, and the fentanyl group received two doses of IV fentanyl 0.5 μg/kg with a five-minute interval between doses. Numeric rating pain scores were compared. During positioning, fentanyl in 0.5 μg/kg increments was given every five minutes until pain scores were ≤4.

Results

There were no statistically significant differences between the groups according to pain scores, need for additional fentanyl, and satisfaction with positioning before spinal block.

Conclusion

We were unable to demonstrate a benefit of FNB over IV fentanyl for patient positioning before spinal block. However, FNB can provide postoperative pain relief, whereas side effects of fentanyl must be considered, and analgesic dosing should be titrated based on pain scores. A multimodal approach (FNB + IV fentanyl) may be a possible option.

Subcapital fracture of the femoral neck in medically unwell patients: technique for fixation using direct infiltration local anaesthetic rather than regional blockade

INTRODUCTION

Patients presenting with fracture of the femoral neck are usually elderly, and often have extensive co-morbidity. Patients who are considered able to survive an operation under general or regional anaesthesia usually undergo surgical stabilisation of the fracture or hemiarthroplasty of the hip for pain relief, to facilitate mobilisation and minimise the risk of developing the sequelae of bed rest. Patients who are considered too unwell for surgery are often treated non-operatively. These patients have a high morbidity and mortality and present significant nursing difficulties.

STUDY

We describe a technique for fixation of subcapital fracture of the femoral neck under local anaesthesia direct infiltration only which is suitable for the medically unwell patient who may otherwise be treated non-operatively. A case series of patients on whom it was performed is presented.

RESULTS

None of the patients required a supplementary anaesthetic technique, all survived to discharge from hospital.

CONCLUSION

We recommend all patients with a subcapital fracture of the femoral neck are offered surgery to optimise their chance of survival and avoid the morbidity associated with bed rest.

[Analgesia after hip fracture repair in elderly patients: the effect of a continuous femoral nerve block: a prospective and randomised study]

INTRODUCTION

The usefulness of peripheral femoral nerve block for pain management after hip fracture has been established. This prospective and randomised study compared the analgesia effect of a continuous femoral nerve block (CF) versus two conventional analgesia procedures after hip fracture.

PATIENTS AND METHODS

Patients. (n=62) scheduled for surgery under spinal anaesthesia were prospectively included. After surgery, analgesia (48 hours) was randomised: group FC (femoral catheter, anterior paravascular approach, initial bolus followed by continuous infusion of ropivacaine 0.2%), group P (iv 2 g propacetamol/6 hours), group M (sc morphine, 0.05 mg/kg per 4 hour). Intravenous morphine titration was performed, followed by subcutaneous (sc) morphine every 4 hours according to the VAS score. The primary end-point was the morphine requirements. Secondary end-points were VAS score, side effects, and mortality.

RESULTS

Demographic data and surgical procedures were similar between groups. After morphine titration, the VAS pain score did not differ between groups. All patients in-group M received additional morphine. Morphine mean consumption was increased in CF group: 26 mg (5-42) versus P: 8 mg (3-12) (p=0.0001) or M: 19 mg (8-33) (p<0.006) while constipation was decreased in P group vs CF. Percentage of patients requiring no morphine was similar between P (n=6; 28%) and CF (n=6; 28%) and greater than M (n=0; 0%). Hospital discharge, cardiovascular or pulmonary complications and mortality after 6 months showed no statistical difference.

CONCLUSION

Continuous femoral nerve block provided limited pain relief after hip fracture did not reduced side effects and induced an expensive cost.

Effect of postoperative epidural analgesia on morbidity and mortality after lung resection in Medicare patients

STUDY OBJECTIVE

To perform an analysis of the Medicare claims database in patients undergoing lung resection to determine whether there is an association between postoperative epidural analgesia and mortality.

DESIGN

Retrospective cohort (database) design.

SETTING

University hospital.

MEASUREMENTS

We examined a cohort of 3501 patients obtained from a 5% nationally random sample of 1997 to 2001 Medicare beneficiaries who underwent nonemergency segmental excision of the lung (International Classification of Diseases, 9th Revision, Clinical Modification codes 32.3 and 32.4). Patient data were divided into two groups depending on the presence or absence of billing for postoperative epidural analgesia (Current Procedural Terminology code 01996). The primary outcomes assessed were death at 7 and 30 days after the procedure. The rates of major morbidity (acute myocardial infarction, angina, cardiac dysrhythmias, heart failure, pneumonia, pulmonary edema, respiratory failure, deep venous thrombosis, pulmonary embolism, sepsis, acute renal failure, somnolence, acute cerebrovascular event, transient organic syndrome, and paralytic ileus) were also compared. Multivariate regression analysis incorporating race, gender, age, comorbidities, hospital size, hospital teaching status, and hospital technology status was performed to determine whether the presence of postoperative epidural analgesia had an independent effect on mortality or major morbidity.

MAIN RESULTS

Multivariate regression analysis showed that the presence of epidural analgesia was associated with a significantly lower odds of death at 7 days (odds ratio, 0.39; 95% confidence interval, 0.19-0.80; P = 0.001) and 30 days (odds ratio, 0.53; 95% confidence interval, 0.35-0.78; P = 0.002) after surgery. There was no difference between the groups with regard to overall major morbidity.

CONCLUSIONS

Postoperative epidural analgesia may contribute to lower odds of death after segmental excision of the lung, although the mechanism of such a benefit is not clear from our analysis.

Does neuraxial anesthesia reduce intraoperative blood loss?

STUDY OBJECTIVE

To perform a meta-analysis of available randomized controlled trials to determine if neuraxial anesthesia would decrease blood loss, compared with general anesthesia.

DESIGN

Retrospective analysis.

SETTING

University medical center.

MEASUREMENTS

The National Library of Medicine's PubMed database was searched from the period of 1966 to December 10, 2003 for all abstracts containing words related to neuraxial anesthesia and general anesthesia. The search was limited to randomized controlled trials and the English language and yielded 667 articles.

MAIN RESULTS

A total of 66 articles met inclusion criteria and were used for the analysis. Overall, the use of spinal anesthesia resulted in significantly less estimated blood loss (EBL) (P < 0.0001), compared with epidural anesthesia (EA), which, in turn, resulted in significantly less EBL compared with general anesthesia (GA) or combined GA-EA (P < 0.0001). No significant difference between GA and GA-EA was noted when analysis was limited to studies directly comparing GA-EA and GA.

CONCLUSIONS

Use of spinal anesthesia or EA is associated with a significant decrease in EBL when compared with that for GA or combined GA-EA.

Regional anesthesia in hip surgery

Historically, general anesthesia has been the "gold standard" for surgeons and patients when major hip surgery is being done. The recent introductions of improved techniques and catheters for continuous peripheral nerve blocks have made regional anesthesia more attractive to patients and surgeons. We focus on current trends and future directions in perioperative pain management for major orthopaedic procedures done on the hip. The use of epidural or spinal anesthesia during major hip surgery has been linked to a reduced risk of perioperative complications like deep venous thrombosis, less deterioration of cerebral and pulmonary functions in patients who are at high risk for complications, and overall reduced blood loss. In addition, continuous peripheral nerve blocks showed effective and safe postoperative pain control, allowing for lower opioids consumption, improved and earlier rehabilitation, and high patient satisfaction. Accurate patient selection and patient education are fundamental for the success of any regional anesthesia technique. Modern regional anesthesia for major hip surgery includes the use of a single shot and continuous epidural injections, single-shot and continuous spinal injection, continuous lumbar plexus blockade, and continuous peripheral blockade of the femoral and sciatic nerves. Continuous peripheral nerve blocks represent an adjunctive, effective, and safe technique for postoperative pain control after total hip arthroplasty. Future directions in postoperative pain control include the creation of a comprehensive system that supervises the use of continuous peripheral nerve blocks outside the acute inpatient setting for few days following the surgical procedure.

LEVEL OF EVIDENCE

Therapeutic study, Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.

The effects of general vs spinal anesthesia on frontal cerebral oxygen saturation in geriatric patients undergoing emergency surgical fixation of the neck of femur

STUDY OBJECTIVE

To assess the effect of regional vs general anesthesia on transcranial cerebral oxygen saturation (rSo2).

DESIGN

Prospective, randomized, open-label study.

SETTING

Large referral hospital.

PATIENTS

Sixty American Society of Anesthesiologists physical status I, II, and III geriatric patients at least 60 years of age, undergoing surgical fixation of the neck of femur.

INTERVENTIONS

Patients were randomized to receive either general (group GA) or spinal (group S) anesthesia. In all cases, frontal rSo2 was measured for a 10-minute preoperative control period, throughout the surgical procedure, and for 10 minutes postoperatively.

MEASUREMENT AND MAIN RESULTS

The frequency of a decrease in rSo2 below baseline preoperative levels was significantly (P < .0001) higher in group S. However, the number of patients in whom at least one dip below baseline was recorded was similar between the groups. By contrast, general anesthesia was associated with a significantly higher rSo2 when compared with spinal anesthesia. Logistic regression revealed no correlation between changes in blood pressure, heart rate, or peripheral oxygen saturation and the frequency of rSo2 dips below baseline.

CONCLUSION

Cerebral oxygen saturation is likely patient specific and independent of the anesthetic technique administered. Spinal anesthesia is associated with a higher incidence of cerebral desaturation. However, the number of patients in whom at least one dip below baseline was recorded was similar between the groups.

The effectiveness of orthopaedic trauma theatres in decreasing morbidity and mortality: a study of 701 displaced subcapital hip fractures in two trauma centres

In countries with universal health care systems patients frequently wait days for their "emergency" surgery. A general trend in orthopaedic traumatology is the advent of daily, dedicated orthopaedic trauma theatres. Availability of trauma theatres is believed to decrease morbidity and mortality, but this remains unproven. A retrospective review comparing morbidity and mortality outcomes between two similar level-one trauma centres (one without a dedicated trauma room system) was undertaken. We reviewed 701 elderly patients receiving hemiarthroplasties for displaced subcapital hip fractures over a 76-month period. Patients were similar between centres in terms of age, gender ratio and comorbidities. Statistically significant differences were found favouring the dedicated trauma room system with approximately half the operative delay and post-operative morbidity. A trend towards decreased mortality was also seen. This study supports the use of regular orthopaedic trauma theatres in tertiary care institutions.

Neuraxial Anesthesia and Low-Molecular-Weight Heparin Prophylaxis in Major Orthopedic Surgery in the Wake of the Latest American Society of Regional Anesthesia Guidelines

In May 2003, the Second American Society of Regional Anesthesia Consensus Conference statement was issued partly in response to continued safety concerns over the use of regional anesthesia--in particular, neuraxial techniques--with low-molecular-weight heparin (LMWH) prophylaxis in major orthopedic surgery. As the 2003 Consensus statement makes clear, regional anesthesia may be used safely with LMWH prophylaxis. The key to optimizing patient safety, however, depends on a careful calibration of the total daily dose and the timing of the first and subsequent doses of the LMWH drug with the timing and management of the regional anesthetic procedure. Because the challenge of successfully providing regional anesthesia in the presence of LMWH thromboprophylaxis is a clinical one, anesthesiologists should do what they can to ensure that every member of the surgical team has an understanding of current literature and practice guidelines such as those recently published by the American Society of Regional Anesthesia.

Rachianesthésie hypobare unilatérale chez le sujet âgé pour la chirurgie traumatique de la hanche : étude pilote

INTRODUCTION

Fractured neck of femur is encountered more frequently as life expectancy increases. All anaesthetic techniques aim to avoid deleterious fall in arterial blood pressure. The haemodynamic effects of hypobaric unilateral spinal anaesthesia have been rarely assessed in patients over 80 year's old. This study aims to do that in a prospective manner.

PATIENTS AND METHODS

Twenty-five patients were enrolled. Following a preload with HES 240/0.576 % (Hesteril) (5 ml/kg) and the administration of an iliofascial block, patients were placed in the lateral decubitus position, operative side uppermost. 3.5 ml of 0.12% hypobaric bupivacaine was administered intrathecally at a rate of 0.25 ml/second. Patients were kept in position for 15 minutes. Systolic, mean and diastolic arterial pressures, heart rate, SaO2 % and ephedrine consumption were recorded at five minutes intervals as was the rate of onset, height and duration of sensory and motor block and extent of bilateralization. Patient and surgeon satisfaction scores were also recorded.

RESULTS

No significant changes in systolic, mean and diastolic pressures, or SaO2 % occurred. Median onset times of sensory and motor block were 8+/-5 and 16+/-7 minutes on the operative side and 30+/-15 and 36+/-15 minutes on the contralateral side in those with bilateralization, respectively. The maximum height of sensory block was T6 for sept patients, T8 for huit patients and T8-T10 for the remainder. Mean duration of sensory and motor block was 134+/-26 and 119+/-24 minutes on the operative side and 100+/-26 and 98+/-25 minutes on the contralateral side, respectively. In 12 patients (48%) bilateralization of their block occurred. Patients and surgeons rated the technique highly.

CONCLUSION

Hypobaric unilateral spinal anaesthesia is a simple technique, produces satisfactory operative conditions and induces very little haemodynamic change in the elderly population.

Epidural Analgesia for Postoperative Pain

Epidural analgesia provides superior analgesia compared with other postoperative analgesic techniques. Additionally, perioperative epidural analgesia confers physiologic benefits, which may potentially decrease perioperative complications and improve postoperative outcome. However, there are many variables (eg, choice of analgesics, catheter-incision congruency, and duration of analgesia) that may influence the efficacy of epidural analgesia. In addition, the use of epidural analgesia should be evaluated on an individual basis because there are risks associated with this technique.

General Anesthesia versus Epidural and General Anesthesia in Radical Cystectomy

INTRODUCTION

The aim of this study is to compare two different anesthetic techniques in radical cystectomy with regard to blood loss, transfusional requirements, intraoperative complications and the quality of analgesia.

MATERIALS AND METHODS

50 patients scheduled for radical cystectomy were randomized to two groups: group GA - general anesthesia, n = 25 and group CEGA - combined epidural and general anesthesia. The patients were monitored and hemodynamic changes, intraoperative bleeding, transfusional requirements, quality of analgesia and postoperative complications were evaluated.

RESULTS

There were no significant differences between the demographic characteristics of the two groups. Intraoperative bleeding which was 874.8 +/- 190.7 ml in the CEGA group and 1,248.3 +/- 343.4 ml in the GA group was statistically different (p < 0.05). Significantly more intraoperative blood transfusions in terms of units were required in the GA group. Analgesia was better in the CEGA group, with VAS values at 0, 1, 2, 4, 6, 12 and 24 h significantly (p < 0.05) lower than those observed in the GA group. No significant differences in intraoperative hemodynamic parameters or postoperative complications were noted between the two groups.

CONCLUSIONS

Statistically significant differences in intraoperative bleeding were observed between the two groups: CEGA provides lower intraoperative bleeding and a better postoperative analgesia. Major operations such as radical cystectomy, which also is associated with considerable blood loss, a combination of general and epidural anesthesia may allow for less blood loss, with a better postoperative analgesia and without any increase in complications.

Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [< or = 3,400 U once daily] (both Grade 1A). For higher risk general surgery patients, we recommend thromboprophylaxis with LDUH (5,000 U tid) or LMWH (> 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).

Anaesthesia for hip fracture surgery in adults

BACKGROUND

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

OBJECTIVES

To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (November 2003), MEDLINE (1996 to February week 2 2004), EMBASE (1988 to 2004 week 10) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional (spinal or epidural) anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The primary outcome was mortality.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Twenty two trials, involving 2567 predominantly female and elderly patients, comparing regional anaesthesia with general anaesthesia were included. All trials had methodological flaws and many do not reflect current anaesthetic practice. Pooled results from eight trials showed regional anaesthesia to be associated with a decreased mortality at one month (56/811 (6.9%) versus 86/857 (10.0%)); however, this was of borderline statistical significance (relative risk (RR) 0.69, 95% confidence interval (CI) 0.50 to 0.95). The results from six trials for three month mortality were not statistically significant, although the confidence interval does not exclude the possibility of a clinically relevant reduction (86/726 (11.8%) versus 98/765 (12.8%), RR 0.92, 95% CI 0.71 to 1.21). The reduced numbers of trial participants at one year, coming exclusively from two trials, preclude any useful conclusions for long-term mortality (80/354 (22.6%) versus 78/372 (21.0%), RR 1.07, 95% CI 0.82 to 1.41).Regional anaesthesia was associated with a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/130 (47%); RR 0.64, 95% CI 0.48 to 0.86). However, this finding is insecure due to possible selection bias in the subgroups in whom this outcome was measured. Regional anaesthesia was also associated with a reduced risk of acute postoperative confusion (11/117 (9.4%) versus 23/120 (19.2%), RR 0.50, 95% CI 0.26 to 0.95). There was insufficient evidence to draw any conclusions from a further four included trials, involving a total of 179 participants, which compared other methods of anaesthesia (a 'light' general with spinal anaesthesia; intravenous ketamine; nerve blocks).

REVIEWERS' CONCLUSIONS

Overall, there was insufficient evidence available from trials comparing regional versus general anaesthesia to rule out clinically important differences. Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes.

Facteurs de qualité de la prise en charge des sujets âgés opérés d’une fracture de l’extrémité supérieure du fémur

Hip fractures are one of the leading causes for admission of elderly subjects to healthcare facilities. Because of population aging, the incidence of hip fractures has increased considerably over the last years and will continue to increase in industrialized countries. Hip fracture in an elderly subject may be life threatening and has a significant functional and social impact not only because of the fracture itself, but also because of the risk of complications related to the patient's health status and the long hospital stay. The purpose of this work was to identify in the published literature professional practices, excepting the surgical procedure, associated with better early and long-term outcome in elderly patients with hip fracture. Questions raised concerning the patient's hospital stay include factors related to the preoperative phase (time to surgery, usefulness of traction), the operation itself (antibiotic prophylaxis, anesthesia technique), and the postoperative phase (prevention of venous thrombosis, malnutrition, episodes of confusion, duration of indwelling bladder catheter, correction of anemia, geriatric care during the stay in the orthopedic ward, early and intense rehabilitation, prevention of recurrence). Among these factors, several appear to be associated with better outcome, including long-term outcome--surgery as early as possible in light of the patient's general status, antibiotic prophylaxis in accordance with standard recommendations (SFAR), prevention of venous thrombosis with low-molecular-weight heparin initiated at admission and associated with elastic contention. Oral nutritional support is probably beneficial and should be proposed for all patients. Particular attention must be given to prevention of confusion in order to reduce the rate of institutionalization. The rythm of rehabilitation exercises should be at least five sessions per week. Finally, there are several methods, which are effective in preventing recurrence, taking into account osteoporosis, risk of falls. Preventive measures should be instituted for all patients undergoing surgery for hip fracture.

General versus spinal anesthesia in patients undergoing radical retropubic prostatectomy: results of a prospective, randomized study

OBJECTIVES

To evaluate the impact of general anesthesia (GA) versus spinal anesthesia (SpA) on intraoperative and postoperative outcome in patients undergoing radical retropubic prostatectomy.

METHODS

Seventy-two consecutive patients with clinically localized prostate cancer were randomized into group 1 (GA: 34 patients) or group 2 (L2-L3 or L3-L4 SpA: 38 patients) and underwent radical retropubic prostatectomy. The intraoperative and postoperative anesthetic and surgical variables were evaluated.

RESULTS

The mean +/- SEM operative time was not significantly different between the two groups (P = 0.43). The overall blood loss was less in group 2 (P = 0.04). The mean +/- SEM postoperative time in the postoperative holding area was significantly shorter after SpA than after GA (P <0.0001). The perioperative pain outcome in the postoperative holding area was significantly better for group 2 than for group 1 (P = 0.0017), but postoperative pain on day 1 was not significantly different between the two groups. The postoperative sedation score was significantly less in group 2 than in group 1 (P <0.0001). On day 1, first flatus passed in a significantly larger number of patients in group 2 (P <0.0001), and the overall gait was greater for group 2 patients (P = 0.02).

CONCLUSIONS

These results suggest that SpA allows good muscle relaxation and a successful surgical outcome in patients undergoing radical retropubic prostatectomy with pelvic lymphadenectomy for clinically localized prostate cancer. Moreover, SpA results in less intraoperative blood loss, less postoperative pain, and a faster postoperative recovery than GA.

Regional Anaesthesia in the Elderly

The number of elderly patients presenting for anaesthesia and surgery has increased exponentially in recent years. Regional anaesthesia is frequently used in elderly patients undergoing surgery. Although the type of anaesthesia (general versus regional anaesthesia) has no substantial effect on perioperative morbidity and mortality in any age group; it intuitively makes sense that elderly patients would benefit from regional anaesthesia because they remain minimally sedated throughout the procedures and awaken with excellent postoperative pain control. However, a multitude of factors influence the outcome, such as the type, duration and invasiveness of the operation, co-existing medical and mental status of the patient and the skill and expertise of the anaesthesiologist and surgeon. These factors make it difficult to decide if and when one technique is equivocally better than another. Thus, it is more important to optimise the overall management of the patient during the perioperative period and, in most cases, it is the quality of the anaesthetic administered rather than the type of anaesthetic which is most important. Sedatives used for regional anaesthesia in the elderly should be short acting, easy to administer, have a low adverse effect profile and high safety margin. Midazolam, lorazepam, ketamine, propofol and low-dose opioids have been successfully used for sedation in the elderly. Aging affects the pharmacokinetics and pharmacodynamics of local anaesthetics, composition and characteristics of tissues and organs within the body, and physiological functions of the body. Changes in the systematic absorption, distribution and clearance of local anaesthetics lead to an increased sensitivity, decreased dose requirement and a change in the onset and duration of action in the elderly. Decreases in neural population, neural conduction velocity and inter-Schwann cell distance can lead to an increased sensitivity to local anaesthetics in the elderly. The addition of an opioid and epinephrine (adrenaline) has been shown to be useful in central neuraxial blockade. Epinephrine also can prolong the duration of peripheral nerve blocks. However, caution must be exercised as epinephrine has the potential for causing ischaemic neurotoxicity in peripheral nerves. Regional anaesthesia appears to be safe and beneficial in elderly patients; however, every anaesthetic administered must be assessed on a case-by-case basis and particular consideration should be given to the health status of the patient, the operation being performed and the expertise of the anaesthesiologist.

Preoperative assessment

Although anaesthetic and surgical procedures should be individualised for every patient, in practice many preoperative protocols and routines are used generally. In this article, we aim to emphasise: why preoperative assessment is important; how it should be done, and by whom; what can be expected; and the importance of test selection based on patients' needs and on scientific evidence of effectiveness. We outline the roles of preoperative medical assessment in otherwise healthy patients. Clinical history, preoperative questionnaires, physical examination, routine tests, individual risk-assessment, and fasting policies are investigated by review of published work. Cost of routine preoperative assessment, the anaesthetist's legal responsibility, and patients'views in the preoperative process are also considered. A thorough clinical preoperative assessment of the patient is more important than routine preoperative tests, which should be requested only when justified by clinical indications. Moreover, this practice eliminates unnecessary cost without compromising the safety and quality of care. Education and training of medical doctors should be more scientifically guided, emphasising the relevance of effectiveness, and cost-effectiveness in clinical decision-making and complemented by audit.

Spinal anaesthesia and the use of anticoagulants

This chapter addresses the increasing incidence of spinal haematoma after central neuraxis anaesthesia in patients receiving drugs that affect coagulation. Administration of low-molecular-weight heparins in the perioperative period is highlighted because these drugs remain the 'gold standard' for prophylaxis against deep-vein thrombosis. The performance of spinal anaesthesia in patients already receiving antiplatelet drugs is discussed--as well as special warnings in such a setting. In addition, issues such as those concerning the administration of unfractionated heparin, anti-vitamin K drugs or new antiplatelet and antithrombotic medications are addressed. Finally, specific recommendations regarding each class of drug are defined in order to avoid the occurrence of a rare but catastrophic event such as spinal haematoma.

Effect of post-operative analgesia on patient morbidity

The pathophysiology that commonly follows surgery results in detrimental physiological effects and may be associated with post-operative mortality and morbidity. The use of post-operative epidural analgesia, but not systemic opioids, may attenuate some of these adverse physiological effects and result in a decrease in patient-related morbidity post-operatively. Randomized trials suggest that the perioperative use of epidural analgesia may facilitate return of gastrointestinal function, attenuate hypercoagulable events and diminish post-operative pulmonary complications. A multimodal approach incorporating the use of epidural analgesia to control perioperative pathophysiology will facilitate the patient's recovery.

Respiratory complications associated with anesthesia

Adverse pulmonary outcomes that follow anesthesia and surgery are often attributed to anesthesia care. PPCs are a significant concern for anesthesia caregivers because they use drugs and techniques that temporarily decrease lung volume, impair airway reflexes, limit immune function, and depress secretion mobilization. A significant component of perioperative risk derives from the surgical site, postoperative pain, and effects of pharmacologic pain management. Rapidly evolving surgical and anesthesia techniques and the introduction of newer pharmaceutical agents make it difficult to identify best practice from retrospective experience reported in the perioperative literature. Prospective studies that deal with specific patient populations, incomparable patient groups or techniques, and unique practice bias have limited validity of claims regarding several promising approaches to perioperative risk reduction. In the absence of clear scientific principles, a perioperative pulmonary risk management strategy for the early part of this century is based on the consensus practice of informed clinicians (Box 4).