Should general anaesthesia be avoided in the elderly?

Locoregional Anesthesia Has Lower Risks of Cardiac Complications Than General Anesthesia After Prolonged Endovascular Repair of Abdominal Aortic Aneurysms

OBJECTIVES

Although general anesthesia is the primary anesthesia in endovascular aneurysm repair (EVAR), some studies suggest locoregional anesthesia could be a feasible alternative for eligible patients. However, most evidence was from retrospective studies and was subjected to an inherent selection bias that general anesthesia is often chosen for more complex and prolonged cases. To mitigate this selection bias, this study aimed to compare 30-day outcomes of prolonged, nonemergent, intact, infrarenal EVAR in patients undergoing locoregional or general anesthesia. In addition, risk factors associated with prolonged operative time in EVAR were identified.

DESIGN

Retrospective large-scale national registry study.

SETTING

American College of Surgeons National Surgical Quality Improvement Program targeted database from 2012 to 2022.

PARTICIPANTS

A total of 4,075 out of 16,438 patients (24.79%) had prolonged EVAR. Among patients with prolonged EVAR, 324 patients (7.95%) were under locoregional anesthesia. There were 3,751 patients (92.05%) under general anesthesia, and 955 of them were matched to the locoregional anesthesia cohort.

INTERVENTIONS

Patients undergoing infrarenal EVAR were included. Exclusion criteria included age <18 years, emergency cases, ruptured abdominal aortic aneurysm, and acute intraoperative conversion to open. Only cases with prolonged operative times (>157 minutes) were selected. A 1:3 propensity-score matching was used to address demographics, baseline characteristics, aneurysm diameter, distant aneurysm extent, and concomitant procedures between patients under locoregional and general anesthesia. Thirty-day postoperative outcomes were assessed. Moreover, factors associated with prolonged EVAR were identified by multivariate logistic regression.

MEASUREMENTS AND MAIN RESULTS

Except for general anesthesia contraindications, patients undergoing locoregional or general anesthesia exhibited largely similar preoperative characteristics. After propensity-score matching, patients under locoregional and general anesthesia had a lower risk of myocardial infarction (0.93% v 2.83%, p = 0.04), but comparable 30-day mortality (3.72% v 2.72%, p = 0.35) and other complications. Specific concomitant procedures, aneurysm anatomy, and comorbidities associated with prolonged EVAR were identified.

CONCLUSIONS

Locoregional anesthesia can be a safe and effective alternative to general anesthesia, particularly in EVAR cases with anticipated complexity and prolonged operative times, as it offers the potential benefit of reduced cardiac complications. Risk factors associated with prolonged EVAR can aid in preoperative risk stratification and inform the decision-making process regarding anesthesia choice.

Factors Associated with Extended Hospitalization in Patients Who Had Adjuvant Middle Meningeal Artery Embolization After Conventional Surgery for Chronic Subdural Hematomas

BACKGROUND

This study aims to evaluate the length of stay (LOS) in patients who had adjunct middle meningeal artery embolization (MMAE) for chronic subdural hematoma after conventional surgery and determine the factors influencing the LOS in this population.

METHODS

A retrospective review of 107 cases with MMAE after conventional surgery between September 2018 and January 2024 was performed. Factors associated with prolonged LOS were identified through univariable and multivariable analyses.

RESULTS

The median LOS for MMAE after conventional surgery was 9 days (interquartile range = 6-17), with a 3-day interval between procedures (interquartile range = 2-5). Among 107 patients, 58 stayed ≤ 9 days, while 49 stayed longer. Univariable analysis showed the interval between procedures, type of surgery, MMAE sedation, and the number of complications associated with prolonged LOS. Multivariable analysis confirmed longer intervals between procedures (odds ratio [OR] = 1.52; P < 0.01), ≥2 medical complications (OR = 13.34; P = 0.01), and neurological complications (OR = 5.28; P = 0.05) were independent factors for lengthier hospitalizations. There was a trending association between general anesthesia during MMAE and prolonged LOS (P = 0.07). Subgroup analysis revealed diabetes (OR = 5.25; P = 0.01) and ≥2 medical complications (OR = 5.21; P = 0.03) correlated with a LOS over 20 days, the 75th percentile in our cohort.

CONCLUSIONS

The interval between procedures and the number of medical and neurological complications were strongly associated with prolonged LOS in patients who had adjunct MMAE after open surgery. Reducing the interval between the procedures and potentially performing both under 1 anesthetic may decrease the burden on patients and shorten their hospitalizations.

Effect of different anesthetic modalities on postoperative delirium in elderly hip fractures: A meta-analysis

BACKGROUND

Previous findings on the effect of general versus spinal anesthesia on postoperative delirium in elderly people with hip fractures are somewhat controversial. This article included the latest randomized controlled study for meta-analysis to evaluate the effect of general anesthesia (GA) and spinal anesthesia (SA) on delirium after hip fracture surgery in the elderly, so as to guide the clinical.

METHODS

Cochrane Library, PubMed, Web Of Science, and Embase were searched from inception up to January 16, 2024. Randomized controlled trial (RCT) was included to evaluate the postoperative results of GA and SA in elderly patients (≥50 years old) undergoing hip fracture surgery. Two researchers independently screened for inclusion in the study and extracted data. Heterogeneity was assessed by the I²and Chi-square tests, and P < .1 or I² ≥ 50% indicated marked heterogeneity among studies. The Mantel-Haenszel method was used to estimate the combined relative risk ratio (RR) and the corresponding 95% confidence interval (CI) for the binary variables.

RESULTS

Nine randomized controlled trials were included. There was no significant difference (RR = 0.93, 95% CI = 0.774-1.111, P > .05) in the incidence of postoperative delirium between the GA group and the SA group. In intraoperative blood transfusion (RR = 1.0, 95% CI = 0.77-1.28, Z = 0.04, P = .971), pulmonary embolism (RR = 0.795, 95% CI = 0.332-1.904, Z = 0.59, P = .606), pneumonia (RR = 1.47, 95% CI = 0.75-2.87, P = .675), myocardial infarction (RR = 0.97, 95% CI = 0.24-3.86, Z = 0.05, P = .961), heart failure (RR = 0.80, 95% CI = 0.26-2.42, Z = 0.40, P = .961), urinary retention (RR = 1.42, 95% CI = 0.77-2.61, Z = 1.11, P = .267) were similar between the 2 anesthetic techniques.

CONCLUSION

There is no significant difference in the effect of GA and SA on postoperative delirium in elderly patients with hip fracture, and their effects on postoperative complications are similar.

Exploring the rationale of performing vaginal hysterectomy under local anaesthesia: A single-centre experience

INTRODUCTION

Vaginal hysterectomy (VH) is usually performed under general (GA) or regional anaesthesia. In recent years, the possibility of performing vaginal hysterectomy under local anaesthesia (LA) has also been explored. Our aim was to compare intraoperative and early postoperative outcomes in women who underwent VH under LA with intravenous sedation or GA.

METHODS

In this retrospective study, we collected data of patients who underwent VH at our department from June 2021 to December 2022. For every patient, the following data was obtained: hospitalisation duration, type of anaesthesia (LA or GA), accompanying procedures, the dosage of used local anaesthetic in the LA group, maximal pain score for each day of hospitalisation after the procedure, procedure duration, intraoperative blood loss, and postoperative complication rate. Data was analysed using the SPSS Statistics programme. Statistical significance was set at p < 0.05.

RESULTS

Seventy patients were included in the study. The mean age was significantly higher in the LA group compared to GA group (73.8 ± 8.0 years vs. 67.1 ± 9.3 respectively, p-value = 0.003). LA was associated with statistically lower pain scores in the first two days after the procedure (p = 0.003), and shorter procedure duration (p-value <0.001) as well as hospitalisation duration (p < 0.001). Furthermore, the cumulative dosage of different analgesics used during hospitalisation was higher in the GA group.

CONCLUSIONS

Our results show that LA is a feasible option for patients undergoing VH. Vaginal surgical procedures under LA could be especially beneficial for older patients with medical comorbidities in whom GA would be particularly hazardous.

Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?

OBJECTIVE

To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED.

METHODS

A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs).

RESULTS

Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8).

CONCLUSIONS

Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.

Comparing Same-Sitting Bilateral vs Unilateral Retrograde Intrarenal Surgery in the Elderly

OBJECTIVE

To compare same-sitting bilateral vs unilateral retrograde intrarenal surgery (RIRS) in elderly patients, focusing on postoperative complications and stone-free rates (SFR).

METHODS

Data from 2 multicenter databases, FLEXible ureteroscopy Outcomes Registry (FLEXOR) (unilateral RIRS) and same sitting bilateral-retrograde intrarenal surgery (SSB-RIRS) (bilateral RIRS), were analyzed, considering only patients aged 70+ with preoperative computed tomography. Patients were categorized into Group 1 (bilateral RIRS) and Group 2 (unilateral RIRS). Follow-up included imaging assessments and secondary treatments as needed.

RESULTS

Group 1 included 146 patients, while group 2 had 495. Group 1's patients were slightly older and had a higher prevalence of recurrent stone formation. Group 2 often underwent RIRS for incidental stones. Group 1 had larger and more pelvic stones. Laser lithotripsy and total operation times were significantly longer in Group 1. Group 2 had significantly higher overall stone-free rates, although there were no significant differences in ancillary procedures for residual fragments. Group 1 experienced more pelvicalyceal injuries needing stenting, postoperative fever, and post-op hematuria not requiring transfusion.

CONCLUSION

In conclusion, bilateral RIRS can be carefully considered in elderly patients. Preoperative counseling is essential for both primary and repeat RIRS procedures, and further research is needed to optimize instrument and laser strategies for better outcomes in elderly RIRS patients.

Relationship Between Newly Established Perioperative DNR Status and Perioperative Outcomes in the Elderly Population: A NSQIP Database Analysis

Background: Health care practitioners have developed complex algorithms to numerically calculate surgical risk. We examined the association between the initiation of a new do-not-resuscitate (DNR) status during hospitalization and postoperative outcomes, including mortality. We hypothesized that new DNR status would be associated with similar complication rates, even though mortality rates may be higher. Methods: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Research File. Two cohorts were defined by the presence of a new DNR status during the hospitalization that was not present on hospital admission. Multivariable logistic regression was used to control for differences between the DNR and non-DNR cohorts. The primary outcome was 30-day mortality. Secondary outcomes included rates of postoperative complications, including returning to the operating room, reintubation, failure to wean from ventilation, surgical site infections, dehiscence, pneumonia, acute kidney injury, renal failure, stroke, cardiac arrest, acute myocardial infarction, transfusion requirements, sepsis, urinary tract infections, venous thromboembolisms, total number of complications for each patient, and hospital length of stay. Results: In our geriatric population with a newly established DNR status, the mortality rate was 39.29%, significantly greater than the non-DNR population after multivariable regression. Secondary outcomes also occurred at an increased rate in the DNR cohort including surgical site infections (8.29% vs 4.04%), pneumonia (18% vs 2.26%), renal insufficiency (2.43% vs 0.35%), acute renal failure (5% vs 0.19%), stroke (3% vs 0.36%), acute myocardial infarction (6.29% vs 0.95%), and cardiac arrest (5.86% vs 0.51%). Conclusions: The initiation of a new DNR status during hospitalization is associated with a significantly higher burden of both morbidity and mortality. This contrasts with prior studies that did not show an increased rate of adverse outcomes and suggests that a new DNR status in postoperative patients may reflect a consequence of adverse postoperative events. The informed consent process in older patients at risk for adverse outcomes after surgery should include discussions regarding goals of care and acceptable risk.

[Telemedical anesthesia consent - Are the patients ready for it? : A comparative requirement analysis before and during the pandemic]

BACKGROUND

Comprehensive anesthesia preparation by means of the anamnesis and physical examination is considered an essential part of the quality criteria for anesthesia. Especially due to the shortage of specialists, there are usually long waiting times in anesthesia outpatient departments and patients must frequently return in cases of missing or pending findings. Telemedicine already offers alternatives in the context of video communication. These alternatives are now particularly prominent due to the currently existing COVID-19 pandemic and the resulting recommendations for digitalization.

OBJECTIVES

This comparative cross-sectional study was carried out to show via a patient survey which patient groups are suitable for a telemedical anesthesia preparation and whether the patients are already technically sufficiently equipped.

MATERIAL AND METHODS

For this purpose, a total of 2080 patients (1030 before and 1050 during the pandemic) were interviewed using a questionnaire. For matched paired analyses, 630 pairs were formed according to their age and gender.

RESULTS

Before and after the pandemic, there was an increase in the percentage of patients already using video communication in their daily lives (30.4% vs. 41.8%). Before the pandemic, 31.7% of patients indicated that they considered this concept of communication to be a practical and appropriate method for an educational conversation and after the pandemic this number increased to 46.6%. For the majority of patients personal contact with a local anesthesiologist was important (80.7% before vs. 67.4% during the pandemic). The number of patients who had the necessary technical equipment for video communication also increased as a result of the COVID-19 pandemic (50.4% vs. 58.2%).

DISCUSSION

Almost half of the patients already seem to be open to a telemedical preoperative evaluation. As digitalization progresses, older generations are more likely to recognize the benefits and be able to own and use the necessary technology in the near future. User acceptance should be the central goal of concept development. This must be followed by a randomized controlled study to evaluate the potentials but also the problems in the perioperative process.

Utility of CT or X-ray in the management of adult nasal fracture

PURPOSE

The primary objective of this study is to evaluate the use of imaging in the management of nasal fracture in adults and determine if imaging is beneficial to clinical decision making when planning for surgery. A secondary objective of this study is to compare surgical rates for nasal fracture between pediatric and adult populations.

METHODS

This is a retrospective case-control study of 357 patients seen at University Hospitals Cleveland Medical Center from January 2015 through January 2020 with a diagnosis of nasal fracture. An odds ratio was calculated to determine likelihood of surgical intervention between patients who had imaging of the nasal bones and patients who did not.

RESULTS

82 % of patients had either CT or X-ray imaging. The odds ratio of patients who had surgery after CT or X-ray imaging compared to patients who had surgery without prior imaging was 0.092 (95 % CI: 0.0448-0.1898, p-value <0.0001). A total of 54 (15 %) adult patients had surgery, in comparison to 50 % of pediatric patients with diagnosis of nasal fracture. 202 (57 %) of patients did not follow up after initial diagnosis by radiology.

CONCLUSION

The statistical analysis suggests that while CT and X-ray are frequently obtained in the setting of nasal fracture, patients without imaging are more likely to have surgery (p < 0.05) than patients with imaging. This indicates that imaging is likely unnecessary for surgical planning. Most adults do not pursue surgery, and surgical rates for adults with nasal fracture are much lower than those of pediatric patients with nasal fracture.

Awake Unilateral Biportal Endoscopic Decompression Under Local Anesthesia for Degenerative Lumbar Spinal Stenosis in the Elderly: A Feasibility Study with Technique Note

Purpose

Here, we introduce a novel strategy of awake unilateral biportal endoscopic (UBE) decompression, which applies conscious sedation combined with stepwise local anesthesia (LA) as an alternative to general anesthesia (GA). The study aims to evaluate the feasibility of awake UBE decompression for degenerative lumbar spinal stenosis (DLSS) in elderly patients.

Patients and Methods

This retrospective study included 31 consecutive patients who received awake UBE decompression for DLSS in our institution from January 2021 to March 2022. Clinical results were evaluated using patient-reported outcomes measures (PROM) including visual analog scale for leg pain (VAS-LP), Oswestry Disability Index (ODI), and modified MacNab criteria. The anesthesia effectiveness and intraoperative experience were evaluated by intraoperative VAS and satisfaction rating system.

Results

UBE decompression was successfully performed in all patients under LA combined with conscious sedation. 26 (83.9%) patients rated the intraoperative experience as satisfactory (excellent or good) and 5 (16.1%) as fair. The mean intraoperative VAS was 3.41±1.26. The VAS and ODI at each follow-up stage after surgery were significantly improved compared to preoperative scores (p < 0.01). At the last follow-up, 28 patients (90.3%) classified the surgical outcome as good or excellent, and 3 (9.7%) as fair. There were no serious complications or adverse reactions observed in the study.

Conclusion

Our preliminary results suggest that awake UBE decompression is a feasible and promising alternative for elderly patients with DLSS.

Patient perception and satisfaction in awake burr hole trepanation under local anesthesia for evacuation of chronic subdural hematoma

Evacuation of chronic subdural hematoma (CSDH) will be one of the most common neurosurgical procedures in the future in the increasingly aging societies. Performing cranial surgery on awake patients may place a psychological burden on them. Aim of this study was to evaluate the psychological distress of patients during awake CSDH relief. Patients with awake evacuation of CSDH via burr hole trepanation were included in our monocentric prospective study. Patient perception and satisfaction were measured using standardized surveys 3-5 days and 6 months after surgery. Among other questionnaires, the Hospital Anxiety and Depression and the Impact of Event Scale, were used to quantify patients' stress. A total of 50 patients (mean age 72.9 years (range 51 - 92)) were included. During surgery, 28 patients reported pain (mean 4.1 (SD 3.3)). Postoperatively, 26 patients experienced pain (mean 2.7 (SD 2.6)). Patients' satisfaction with intraoperative communication was reported with a mean of 8.3 (SD 2.1). There was a significant negative correlation between intraoperatively perceived pain and satisfaction with intraoperative communication (p = 0.023). Good intraoperative communication during evacuation of CSDH in awake patients is associated with positive patient perception and correlates with pain reduction.

Awake robotic liver surgery: A case report

BACKGROUND

In recent years, minimally invasive liver resection has become a standard of care for liver tumors. Considering the need to treat increasingly fragile patients, general anesthesia is sometimes avoided due to respiratory complications. Therefore, surgical treatment with curative intent is abandoned in favor of a less invasive and less radical approach. Epidural anesthesia has been shown to reduce respiratory complications, especially in elderly patients with pre-existing lung disease.

CASE SUMMARY

A 77-year-old man with hepatitis-C-virus-related chronic liver disease underwent robotic liver resection for hepatocellular carcinoma. The patient was suffering from hypertension, diabetes and chronic obstructive pulmonary disease. The National Surgical Quality Improvement Program score for developing pneumonia was 9.2%. We planned a combined spinal-epidural anesthesia with conscious sedation to avoid general anesthesia. No modification of the standard surgical technique was necessary. Hemodynamics were stable and bleeding was minimal. The postoperative course was uneventful.

CONCLUSION

Robotic surgery in locoregional anesthesia with conscious sedation could be considered a safe and suitable approach in specialized centers and in selected patients.

A survey of surgical patients' perspectives and preferences towards general anesthesia techniques and shared-decision making

BACKGROUND

The decision about which type of general anesthetic to administer is typically made by the clinical team without patient engagement. This study examined patients' preferences, experiences, attitudes, beliefs, perceptions, and perceived social norms about anesthesia and about engaging in the decision regarding general anesthetic choice with their clinician.

METHODS

We conducted a survey in the United States, sent to a panel of surgical patients through Qualtrics (Qualtrics, Provo, UT) from March 2022 through May 2022. Questions were developed based on the Theory of Planned Behavior and validated measures were used when available. A patient partner who had experienced both intravenous and inhaled anesthesia contributed to the development and refinement of the questions.

RESULTS

A total of 806 patients who received general anesthesia for an elective procedure in the last five years completed the survey. 43% of respondents preferred a patient-led decision making role and 28% preferred to share decision making with their clinical team, yet only 7.8% reported being engaged in full shared decision making about the anesthesia they received. Intraoperative awareness, pain, nausea, vomiting and quickly returning to work and usual household activities were important to respondents. Waking up in the middle of surgery was the most commonly reported concern, despite this experience being reported only 8% of the time. Most patients (65%) who searched for information about general anesthesia noted that it took a lot of effort to find the information, and 53% agreed to feeling frustrated during the search.

CONCLUSIONS

Most patients prefer a patient-led or shared decision making process when it comes to their anesthetic care and want to be engaged in the decision. However, only a small percentage of patients reported being fully engaged in the decision. Further studies should inform future shared decision-making tools, informed consent materials, educational materials and framing of anesthetic choices for patients so that they are able to make a choice regarding the anesthetic they receive.

Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis

BACKGROUND

With the increase in life expectancy around the globe, the incidence of postoperative delirium (POD) among older people (≥65 years) is growing. Previous studies showed a wide variation in the incidence of POD, from 4% to 53%, with a lack of specific evidence about the incidence of POD by specific surgery type among older people. The aim of this systematic review and meta-analysis was to determine the incidence of POD by surgery type within populations 65 years and over.

METHODS

Databases including PubMed, Cochrane library, Embase, and CINAHL were searched until October 2020. Due to the relatively higher number of meta-analyses undertaken in this area of research, a streamlined systematic meta-analysis was proposed.

RESULTS

A total of 28 meta-analyses (comprising 284 individual studies) were reviewed. Data from relevant individual studies (n = 90) were extracted and included in the current study. Studies were grouped into eight surgery types and the incidence of POD for orthopedic, vascular, spinal, cardiac, colorectal, abdominal, urologic, and mixed surgeries was 20%, 14%, 13%, 32%, 14%, 30%, 10%, and 26%, respectively. POD detection instruments were different across the studies, with Confusion Assessment Method (CAM & CAM-ICU) being the most frequently adopted.

LINKING EVIDENCE TO ACTION

This study showed that POD incidence in older people undergoing surgery varied widely across surgery type. The more complex surgeries like cardiac and abdominal surgeries were associated with a higher risk of POD. This highlights the need to include the level of surgery complexity as a risk factor in preoperative assessments.

The Lateral Femoral Cutaneous and Over the Hip (LOH) Block for the Surgical Management of Hip Fractures: A Safe and Effective Anesthetic Strategy

OBJECTIVES

To examine the efficacy of regional anesthesia with sedation only for a variety of hip fractures using the newly described lateral femoral cutaneous with over the hip (LOH) block.

DESIGN

Retrospective.

SETTING

Orthopedic specialty hospital.

PATIENTS/PARTICIPANTS

40 patients who presented between November 2021 and February 2022 for fixation of OTA/AO 31.A1-3 and 31.B1-3 fractures. Matched cohorts of 40 patients who received general anesthesia and 40 patients who received spinal anesthesia for hip fracture fixation were also used.

INTERVENTION

Operative fixation under LOH block and sedation only. The LOH block is a regional hip analgesic that targets the lateral femoral cutaneous nerve, articular branches of femoral nerve, and accessory obturator nerve.

MAIN OUTCOME MEASUREMENTS

Demographics, intraoperative characteristics, anesthesia-related complications, hospital quality metrics, and short-term mortality and reoperation rates.

RESULTS

A total of 120 patients (40 each: general, spinal, and LOH block) were compared. The cohorts were similar in age, race, body mass index, sex, Charlson comorbidity index, trauma risk score, ambulatory status at baseline, fracture type, and surgical fixation technique performed. Physiologic parameters during surgery were more stable in the LOH block cohort ( P < 0.05). Total OR time and anesthesia time were the shortest for the LOH block cohort ( P < 0.05). Patients in the LOH block cohort also had lower postoperative pain scores ( P < 0.05). Length of hospital stay was the shortest for patients in the LOH block cohort ( P < 0.05), and during discharge, patients in the LOH block cohort ambulated the furthest ( P < 0.05). No differences were found for anesthesia-related complications, palliative care consults, major and minor hospital complications, discharge disposition, reoperation and readmission rates, and mortality rates.

CONCLUSIONS

The LOH block is safe and effective anesthesia for the treatment of all types of hip fractures in the elderly patients requiring surgery. In addition, this block may decrease postoperative pain and length of hospital stay, and allow for greater ambulation in the early postoperative period for patients with hip fracture.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Identifying High Direct Variable Costs of Open Carpal Tunnel Release Patients Using Time-Driven Activity-Based Costing

PURPOSE

To improve value in health care delivery, a deeper understanding of the cost drivers in hand surgery is necessary. Time-driven activity-based costing (TDABC) more accurately reflects true resource use compared with traditional accounting methods. This study used TDABC to explore the facility cost of carpal tunnel release and identify preoperative characteristics of high-cost patients.

METHODS

Using TDABC, we calculated the facility costs of 516 consecutive patients undergoing open carpal tunnel release at an orthopedic specialty hospital between 2015 and 2021. Patients in the top decile cost were defined as high-cost patients. Multivariable logistic regression was used to determine preoperative characteristics (age, sex, body mass index, race, ethnicity, Elixhauser comorbidity index, American Society of Anesthesiology score, preoperative Disabilities of the Arm, Shoulder and Hand score, Short-Form 12, and anesthesia type) independently associated with high-cost patients.

RESULTS

Surgery-related personnel costs were the main driver (38.0%) of total facility costs, followed by preoperative personnel costs (21.3%). There was a 1.8-fold variation in facility cost between patients in the 90th and 10th percentiles ($774.69 vs $431.35), with the widest cost variations belonging to medication costs ($17.67 vs $1.85; variation, 9.6-fold) and other supply costs ($213.56 vs $65.56; variation, 3.3-fold). Using multivariable regression, predictors of high cost were patient age and use of general anesthesia. Total facility costs correlated strongly with the total operating room time and incision to closure time.

CONCLUSIONS

Efforts to decrease operating room time may translate into reduced personnel costs and greater cost savings. Multidisciplinary initiatives to control medication expenses for patients at risk of high costs may narrow the existing variation in costs.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analysis II.

Neuraxial anesthesia in hepato-pancreatic-bilio surgery: a first western pilot study of 46 patients

The most common anesthetic approach in hepato-pancreatic-biliary (HPB) surgery is general anesthesia (GA), but it may result in increased morbidity and mortality and peri-operative risks especially in frail patients. The aim of this study was to assess the safety and effectiveness of neuraxial anesthesia (NA) in HPB in a pilot clinical series. This analysis was conducted on 46 consecutive patients undergoing HPB surgery in an Italian Tertial referral center. Data were prospectively collected and retrospectively analyzed. continuous spinal anesthesia (CSA), combined spino-epidural anesthesia (CSEA) and peridural anesthesia (PA) were used in major and minor hepatectomies and bilio-pancreatic surgery instead of GA. NA was evaluated by analyzing the surgical and anesthesiological short-term outcomes. 46 patients were considered eligible for the study between February 2018 and May 2020. The average age was 69.07 (±  9.95) years. 22 were males and 24 were females. According to the ASA score, 19 (41.30%) patients had ASA II, 22 (47.83%) had ASA III and 5 (10.87%) had ASA IV. 22 (47.83%) patients underwent CSA, 20 (43.48%) CSEA and 4 (8.69%) PA. We performed 8 major and 19 minor hepatectomies, 7 bilio-digestive derivations, 5 Whipple procedures, 4 iatrogenic biliary duct injuries, 2 splenopancreatectomies and 1 hepatic cyst fenestration. Clavien-Dindo ≥ 3 was observed in 3 patients. The conversion rate to endotracheal intubation occurring in 3 of 46 (6.52%) patients. After surgery, no local or pulmonary complications and delirium were reported in our series. The present study demonstrates that NA is a safe and feasible option in selected patients, if performed in referral centers by well-trained anaesthesiologists and surgeons.

Surveillance and office management of low-grade Ta bladder tumors

OBJECTIVE

Patients with low-grade (LG), grade 1-2, Ta bladder cancer (BC) will frequently have a "recurrence". However, they rarely progress in stage. Although current guidelines mention surveillance and office management for these new or recurrent tumors, transurethral resection (TURBT) is the most common treatment. The purpose of this study is to determine if surveillance and/or office cautery is safe.

MATERIALS AND METHODS

This study was conducted as a retrospective case series analysis of 45 patients who had recurrent LG Ta appearing bladder cancer (BC) and were managed primarily with surveillance and/or office cautery. Patients with carcinoma in-situ were excluded. The primary outcome was stage progression.

RESULTS

Median follow up was 62 months. 41 (91%) patients did not progress in stage. Three patients recurred with HG T1 BC; one is receiving systemic immunotherapy. One patient developed HG T2 BC and was treated with a bladder preservation protocol. 40 (89%) patients underwent office cauterization. Eleven received BCG and 26 received post-cautery intravesical chemotherapy. Five (11%) patients developed HG BC during follow up. No patients died. None of the 17 (38%) Hispanic patients had progression.

CONCLUSIONS

Active surveillance and/or office cautery for patients with small recurrent LG Ta bladder tumors is safe, reduces cost and improves quality of life by avoiding TURBTs.

Reactive oxygen species contribute to delirium-like behavior by activating CypA/MMP9 signaling and inducing blood-brain barrier impairment in aged mice following anesthesia and surgery

Postoperative delirium (POD) is common in the elderly and is associated with poor clinical outcomes. Reactive oxygen species (ROS) and blood-brain barrier (BBB) damage have been implicated in the development of POD, but the association between these two factors and the potential mechanism is not clear. Cyclophilin A (CypA) is a specifically chemotactic leukocyte factor that can be secreted in response to ROS, which activates matrix metalloproteinase 9 (MMP9) and mediates BBB breakdown. We, therefore, hypothesized that ROS may contribute to anesthesia/surgery-induced BBB damage and delirium-like behavior via the CypA/MMP9 pathway. To test these hypotheses, 16-month-old mice were subjected to laparotomy under 3% sevoflurane anesthesia (anesthesia/surgery) for 3 h. ROS scavenger (N-acetyl-cysteine) and CypA inhibitor (Cyclosporin A) were used 0.5 h before anesthesia/surgery. A battery of behavior tests (buried food test, open field test, and Y maze test) was employed to evaluate behavioral changes at 24 h before and after surgery in the mice. Levels of tight junction proteins, CypA, MMP9, postsynaptic density protein (PSD)-95, and synaptophysin in the prefrontal cortex were assessed by western blotting. The amounts of ROS and IgG in the cortex of mice were observed by fluorescent staining. The concentration of S100β in the serum was detected by ELISA. ROS scavenger prevented the reduction in TJ proteins and restored the permeability of BBB as well as reduced the levels of CypA/MMP9, and further alleviated delirium-like behavior induced by anesthesia/surgery. Furthermore, the CypA inhibitor abolished the increased levels of CypA/MMP, which reversed BBB damage and ameliorated delirium-like behavior caused by ROS accumulation. Our findings demonstrated that ROS may participate in regulating BBB permeability in aged mice with POD via the CypA/MMP9 pathway, suggesting that CypA may be a potential molecular target for preventing POD.

Clinically Optimal Neuropsychological Tests for Postoperative Cognitive Dysfunction in Heart Valve Surgeries

BACKGROUND

Postoperative cognitive dysfunction (POCD) is widely recognized and reported, but the lack of a uniform definition makes it difficult to evaluate its clinical impact. The aim of this study is to establish the optimal neuropsychological tests and definition of POCD relevant to clinical outcomes in heart valve surgeries.Methods and Results: Between June 2015 and December 2019, 315 patients undergoing elective heart valve surgeries (age ≥65 years) were enrolled. The Mini-Mental Status Examination, Montreal Cognitive Assessment (MoCA), and the Trail Making Test A and B were performed to evaluate cognitive function. Clinical endpoints were defined as readmission and death. The postoperative readmission and death rate were 17% and 3% (54/315 and 8/315; follow-up 266-1,889 days). By multivariable Cox hazard analysis, Short Physical Performance Battery (adjusted hazard ratio [HR]: 0.84, 95% confidence interval [CI]: 0.49-0.98, P=0.001), MoCA change rate (adjusted HR: 0.64, 95% CI: 0.01-1.22, P=0.024), and intensive care unit stay (adjusted HR: 0.55%, 95% CI: 0.99-1.12, P=0.054) were detected as independent risk factors for combined events. The cutoff value was -12% in the change rate of MoCA.

CONCLUSIONS

MoCA was the only neuropsychological test that predicted the clinical impact on complex events and has the potential to define POCD.

Patient tolerability during office cystoscopy and bladder tumor cauterization: a multivariate analysis of risk factors

OBJECTIVE

Cystoscopy and cauterization performed in the operating room is expensive and exposes patients to anesthesia risks. Patient tolerability during office cystoscopy and cauterization is critical to the office management of bladder cancer (BC) and other urologic diseases. We evaluated the risk factors for pain of flexible cystoscopy in the office-setting with emphasis on a sub-group of BC patients who underwent cauterization.

MATERIALS AND METHODS

Retrospective analyses of 110 anonymous patient surveys completed after cystoscopy and/or cauterization. Survey information included age, gender, indication for cystoscopy, number of prior cystoscopies, number of prior office-based cauterizations, anxiety prior/during cystoscopy, and pain during cystoscopy and/or cauterization. Univariate/multivariate and linear-regression analyses were performed to evaluate the association of pain with clinical parameters.

RESULTS

Average pain during cystoscopy (1.75 ± 1.331) was not significantly different when cauterization was also performed (2.37 ± 2.214) (p < 0.001) (p = 0.2840). Patients in the lower age group (<66 years) indicated higher anxiety levels (p = 0.0005), more pain at cystoscopy (P = 0.004) and cauterization (p < 0.001). Although the patients' overall anxiety level was low (1-3/10), it was associated with some pain during cystoscopy (p = 0.0005) and cauterization (p < 0.000). In multivariate analysis, anxiety was the only independent predictor of pain during cystoscopy (p = 0.03, OR: 6.52,95% CI: 1.2-35.6) and cauterization (p = 0.0012, OR: 3.4, 95%CI: 1.6-7.0). In BC patients, pain scores during cystoscopy and cauterization were not significantly different (p = 0.4772) but associated with anxiety.

CONCLUSION

Office-based cystoscopy and cauterization are tolerable with minimal pain. Higher pain levels during cystoscopy were associated with procedure anxiety, and pain during cauterization was associated with procedure anxiety and younger age. Younger and more anxious patients may need more counseling before cystoscopy.

Femoral and Lateral Femoral Cutaneous Nerve Block as Anesthesia for High-Risk Intertrochanteric Fracture Repair Patients

Introduction. Intertrochanteric fracture (IF) is a common injury among the elderly. Due to significant comorbidities, anesthesia for IF repair may be challenging. The authors propose femoral nerve block together with a lateral femoral cutaneous nerve block and sedation as an anesthetic technique for most severe cases of IF with contraindications to spinal anesthesia. Methods. In total, 61 patients were enrolled prospectively in a study, 19 received general anesthesia (GA group), 22 spinal anesthesia (SA group), and 20 nerve blocks with sedation (PNB group). Results. Groups were comparable in terms of age, gender, independence, and several comorbidities: diabetes, obesity, underweight, cardiovascular, and cerebrovascular incidents in the past, dementia, chronic obstructive pulmonary disease, and frailty. Heart failure (p = 0.033), hemoglobin < 10 g/dL (p = 0.001) and eGFR < 30 mL/min (p = 0.039) were more frequent in PNB group. PNB group had higher American Society of Anesthesiologists (ASA) (p < 0.001), Nottingham Hip Fracture Score (NHFS) (p < 0.001), and Charlson Comorbidity Index (CCI) (p = 0.002) scales scores, and lower probability of 10-year survival according to CCI (p = 0.012). GA group had more frequent active malignancy (p = 0.041). GA and PNB groups had a higher frequency of hemostasis disorder (p < 0.001). Surgery was completed under the scheduled anesthesia technique. Survival, frequency of cardio and cerebrovascular incidents after surgery, loss of independence, and postoperative delirium were comparable between groups, as well as the length of postoperative stay. Conclusions. Surgical repair of intertrochanteric fracture with intramedullary nailing system among elderly, frail, and sick patients can be conducted under peripheral nerve block. FNB and LFCNB in the combination is a viable option for IT fracture repair.

Identifying relationships between kinesiophobia, functional level, mobility, and pain in older adults after surgery

BACKGROUND

Further data on the causes of functional independence or disability after surgery are needed to explain the clinical decision-making process for older patients, their families, and policy-makers. There are a limited number of studies showing the relationship between kinesiophobia, functional status, pain and mobility in older adults after surgery.

AIMS

The study aims to investigate relationships among kinesiophobia, pain, mobility, and functional status in older adults after surgery.

METHODS

A comparative-descriptive and cross-sectional study. The research was conducted with 99 older adults in the general surgery clinic after surgery. A Visual Analogue Scale was used to evaluate pain levels, the Standardized Mini-Mental State Examination to evaluate mental function status, the Functional Independence Measure to assess functional independence in daily activities, the Rivermead Mobility Index to evaluate basic mobility in daily life, and the Tampa Scale for Kinesiophobia to assess fear of mobility.

RESULTS

Regression analysis revealed a significant negative correlation between social security and kinesiophobia, and also between functional level and type of anesthesia and mental status in older women (R² = - 0.185, p = 0.005; R² = - 0.167, p = 0.011 and p = 0.005, respectively).

DISCUSSION

In the literature, there are no standardized procedures during the evaluation and rehabilitation of older adults after abdominal or thoracic surgery, etc. operations. This study will contribute to the current literature by attracting interest in this field and increasing the evaluations performed.

CONCLUSIONS

The study findings emphasize the importance of evaluating the functional, mobility, mental and kinesiophobic status of older adults after surgery in clinics, rehabilitation centers, or research.

A randomized trial: bispectral-guided anesthesia decreases incidence of delayed neurocognitive recovery and postoperative neurocognitive disorder but not postoperative delirium

BACKGROUND

Postoperative cognitive dysfunction (POCD), also known as delayed neurocognitive recovery (up to 30 days) and postoperative neurocognitive disorder (up to 12 months), is a frequent complication of the neurological system associated with poor outcome. This randomized controlled trial aimed to determine whether bispectral (BIS) monitoring is correlated with delayed neurocognitive recovery, postoperative neurocognitive disorder, or postoperative delirium (POD).

METHODS

Among 197 patients included in the study, 100 were assigned to the BIS group and 97 to the control group. The BIS index was kept at 40-60 in the BIS group, and the depth of anesthesia in the control group was maintained according to anesthetists' clinical experience. Cognitive function was evaluated from the 1^st-7^th day after the operation and the time of discharge, and at 1^st month, 6^th months, and 1 year after the operation.

RESULTS

The incidence of delayed neurocognitive recovery (3% vs. 21.6%, P<0.001, at 7^th day) (3% vs. 21.1%, P<0.001, at 1^st month) and postoperative neurocognitive disorder (6.2% vs. 21.3%, P=0.002, at 6^th month) (4.4% vs. 16.3%, P=0.009, at 1 year) were lower in the BIS group, while there was no significant difference in POD between the two groups (12% vs. 19.6%, P=0.144). The average value of intraoperative BIS was lower in the BIS group (43.75 vs. 50.69, P<0.001). The postoperative hospitalization time (9.99 vs. 12.41, P<0.001) and the mortality (5.4% vs. 14.4%, P=0.042) were significantly decreased, while satisfaction was higher in the BIS group (39% vs. 24.7%, P=0.009).

CONCLUSION

BIS decreases delayed neurocognitive recovery and postoperative neurocognitive disorder; however, it is not associated with POD. BIS monitoring could effectively lessen postoperative hospitalization and mortality and increase patient satisfaction.

Simple and Efficient Pressure Ulcer Reconstruction via Primary Closure Combined with Closed-Incision Negative Pressure Wound Therapy (CiNPWT)—Experience of a Single Surgeon

Background: In this study, we aimed to analyze the clinical efficacy of closed-incision negative pressure wound therapy (CiNPWT) when combined with primary closure (PC) in a patient with pressure ulcers, based on one single surgeon’s experience at our medical center. Methods: We retrospectively reviewed the data of patients with stage III or IV pressure ulcers who underwent reconstruction surgery. Patient characteristics, including age, sex, cause and location of defect, comorbidities, lesion size, wound reconstruction methods, operation time, debridement times, application of CiNPWT to reconstructed wounds, duration of hospital stay, and wound complications were analyzed. Results: Operation time (38.16 ± 14.02 vs. 84.73 ± 48.55 min) and duration of hospitalization (36.78 ± 26.92 vs. 56.70 ± 58.43 days) were shorter in the PC + CiNPWT group than in the traditional group. The frequency of debridement (2.13 ± 0.98 vs. 2.76 ± 2.20 times) was also lower in the PC + CiNPWT group than in the traditional group. The average reconstructed wound size did not significantly differ between the groups (63.47 ± 42.70 vs. 62.85 ± 49.94 cm²), and there were no significant differences in wound healing (81.25% vs. 75.38%), minor complications (18.75% vs. 21.54%), major complications (0% vs. 3.85%), or mortality (6.25% vs. 10.00%) between the groups. Conclusions: Our findings indicate that PC combined with CiNPWT represents an alternative reconstruction option for patients with pressure ulcers, especially in those for whom prolonged anesthesia is unsuitable.

The effect of type 2 diabetes mellitus on perioperative neurocognitive disorders in patients undergoing elective noncardiac surgery under general anesthesia. A prospective cohort study

Background and Aims:

Preliminary evidence suggests a possible relationship between type 2 diabetes mellitus (T2DM) and perioperative neurocognitive disorders (NCD). We sought to investigate whether patients with T2DM, undergoing elective noncardiac surgery under general anesthesia, are at increased risk of perioperative NCD.

Material and Methods:

A prospective cohort study was designed. One-hundred and forty-four patients with T2DM and 144 healthy controls were recruited. Controls were matched for sex, age, type of operation, and educational background. Postoperative delirium (POD), delayed neurocognitive recovery and postoperative NCD were evaluated.

Results:

Two hundred twenty-eight patients were analyzed. Compared to controls, patients with T2DM were diagnosed with higher rates of NCD preoperatively (n = 96 vs. n = 26, P < 0.05) and higher POD up to 4 days postoperatively (n = 204 vs. n = 68, P < 0.05). Increased rates of delayed neurocognitive recovery and postoperative NCD were recorded in patients with T2DM up to 9 months postoperatively (n = 473 vs. n = 192, P < 0.05). Insulin-dependent patients had higher rates of POD on the second (n = 38 vs. n = 24, P < 0.05) and third day (n = 27 vs. n = 16, P < 0.05) when compared to noninsulin-dependent patients. Logistic multivariable analysis revealed that patients with T2DM are at increased risk for postoperative cognitive disorders.

Conclusion:

Patients with type 2 diabetes mellitus appear to be at a higher risk of perioperative NCDs up to 9 months after elective noncardiac surgery under general anesthesia.

Age-related differences in cognition and postoperative quality of recovery after beach chair position shoulder surgery

We examined the influence of age in beach chair position shoulder surgery and postoperative quality of recovery by conducting a single-site, observational, cohort study comparing younger aged (18-40 years) versus older aged (at least 60 years) patients admitted for elective shoulder surgery in the beach chair position. Endpoints were dichotomous return of function to each patient's individual preoperative baseline as assessed using the postoperative quality of recovery scale; measuring cognition, nociception, physiological, emotional, functional activities and overall perspective. We recruited 112 (41 younger and 71 older aged) patients. There was no statistical difference in cognitive recovery at day three postoperatively (primary outcome): 26/32 younger patients (81%) versus 43/60 (72%) older patients, P=0.45. Rates of recovery were age-dependent on domain and time frame (secondary outcomes), with older patients recovering faster in the nociceptive domain (P=0.02), slower in the emotional domain (P=0.02) and not different in the physiological, functional activities and overall perspective domains (all P >0.35). In conclusion, we did not show any statistically significant difference in cognitive outcomes between younger and older patients using our perioperative anaesthesia and analgesia management protocol. Irrespective of age, 70% of patients recovered by three months in all domains.

Intranasal Dexmedetomidine in Elderly Patients (Aged > 65 Years) During Maxillofacial Surgery: Sedative Properties and Safety Analysis

PURPOSE

Light sedation rather than intravenous sedation is preferred when patients have a low heart rate and blood pressure during maxillofacial surgery. Intranasal administration of dexmedetomidine is reported to be efficacious and safe in adults. However, dexmedetomidine could be unsuitable for routine clinical use in elderly patients because many of these patients take β-blockers, which increase the cardiovascular effects of dexmedetomidine. The objectives of the study were to evaluate the sedative properties and safety of intranasal dexmedetomidine, regardless of concurrent β-blocker treatment, in elderly patients who underwent maxillofacial surgery.

METHODS

This study was a retrospective analysis of 535 patients aged > 65 years (American Society of Anesthesiologists physical status I or II) who were undergoing maxillofacial surgery. Very anxious patients and those with hypertension received intranasal 1 µg/kg dexmedetomidine through an intranasal mucosal atomization device before anesthesia (local ropivacaine).

RESULTS

Intranasal administration of dexmedetomidine decreased the requirement for midazolam before surgery (18 of 252 vs 63 of 283, P < .0001), but increased the requirement for norepinephrine (102 of 252 vs 8 of 283, P < .0001) during or after the surgery. A combination of a β-blocker and intranasal administration of dexmedetomidine reduced the hemodynamic parameters for an extended period. Intranasal administration of dexmedetomidine resulted in bradycardia and hypotension, regardless of concurrent β-blocker treatment.

CONCLUSIONS

Intranasal 1 µg/kg dexmedetomidine was associated with a high sedation score during the operation, but also with bradycardia and hypotension.

Chronic Subdural Hematoma Drainage Under Local Anesthesia with Sedation versus General Anesthesia and Its Outcome

BACKGROUND

Burr hole drainage is the criterion standard treatment for chronic subdural hematoma (CSDH), a common neurosurgical condition. However, apart from the surgical technique, the method of anesthesia also has a significant impact on postoperative patient outcome. Currently, there are limited studies comparing the use of local anesthesia with sedation (LA sedation) versus general anesthesia (GA) in the drainage of CSDH. The objective of this study was to compare the morbidity and mortality outcomes of using LA sedation versus GA in CSDH burr hole drainage.

METHODS

This retrospective study presents a total of 257 operations in 243 patients from 2 hospitals. A total of 130 cases were operated under LA sedation in hospital 1 and 127 cases under GA in hospital 2. Patient demographics and presenting features were similar at baseline.

RESULTS

Values are shown as LA sedation versus GA. Postoperatively, most patients recovered well in both groups with Glasgow Outcome Scale scores of 4-5 (96.2% vs. 88.2%, respectively). The postoperative morbidity was significantly increased by an odds ratio of 5.44 in the GA group compared with the LA sedation group (P = 0.005). The mortality was also significantly higher in the GA group (n = 5, 3.9%) than the LA sedation group (n = 0, 0.0%; P = 0.028). The CSDH recurrence rate was 4.6% in the LA sedation group versus 6.3% in the GA group. No intraoperative conversion from LA sedation to GA was reported.

CONCLUSIONS

This study demonstrates that CSDH drainage under LA sedation is safe and efficacious, with a significantly lower risk of postoperative mortality and morbidity when compared with GA.

Long‐term outcomes of outpatient laser ablation for recurrent non‐muscle invasive bladder cancer: A retrospective cohort study

Objectives

The objective of this study is to determine the long‐term efficacy and safety of office‐based Holmium:YAG laser ablation for the treatment of recurrent non‐muscle‐invasive bladder cancer (NMIBC).

Methods

We retrospectively reviewed the medical records of all consecutive patients who underwent office‐based laser ablation for recurrent bladder cancer between 2008 and 2016. The following data were collected: original histology, date of original histology, date of laser ablation, number of repeat laser ablation procedures required, date of tumor recurrence or progression, number of general anesthesia procedures (transurethral resection or cystodiathermy) required after first laser ablation, and number and severity of complications. Kaplan–Meier survival curves were produced for recurrence‐free survival, progression‐free survival, and overall survival.

Results

A total of 97 patients, with an average age of 84 (62–98) years and an average Charlson Comorbidity Index of 6.9 (4–13), were included. The median follow‐up was 61 (2–150) months. Fifty‐five (56.7%) patients presented with tumor recurrence, and the median recurrence‐free survival time was 1.69 years (95% CI 1.20–2.25). Only 9 (9.3%) patients had evidence of tumor progression to a higher grade or stage, 8 (89%) of which initially had low‐grade tumors; however, no patient progressed to muscle‐invasive disease. The median progression‐free survival time was 5.70 years (95% CI 4.10–7.60), and the median overall survival time was 7.60 years (95% CI 4.90–8.70). No patient required emergency inpatient admission after laser ablation.

Conclusion

Office‐based Holmium:YAG laser ablation offers a safe and effective alternative method for treating low‐volume, low‐grade recurrent NMIBC, especially in elderly patients with significant co‐morbidity, while avoiding general anesthesia and inpatient admission.

Cochlear implantation under local anesthesia in 117 cases: patients' subjective experience and outcomes

Purpose

To report the outcomes and the patients’ subjective experience of cochlear implantation (CI) performed under local anesthesia (LA). To describe a new form of intraoperative cochlear monitoring based on the patients subjective sound perception during CI.

Methods

In this retrospective case–cohort study, 117 patients underwent CI under LA with (n = 58) or without conscious sedation (n = 59). Included were primarily elderly patients with elevated risks for general anesthesia and recently patients with residual hearing eligible for electro-acoustic stimulation (EAS) (n = 27), in whom hearing could be monitored during the electrode insertion. A 500 Hz test tone was presented and the patient reported  of subjective changes in loudness, leading to a modification of the insertion. A questionnaire was sent to all patients in which they assessed their subjective experience.

Results

All patients were successfully operated under LA without the need to intraoperatively convert to general anesthesia. 90% of the patients reported that the surgery was a positive experience. The vast majority, 90% of patients were satisfied with the overall treatment and with intraoperative pain management and 84% of the patients would opt for local anesthesia again. Cochlear monitoring by the patients’ subjective sound perception enabled for atraumatic insertions as all EAS patients could hear the test tone up to the end of the surgery.

Conclusions

CI under LA was well tolerated and recommended by the vast majority of patients. In addition, it offers the possibility to monitor the patients’ hearing during the electrode insertion, which may help to prevent insertion trauma.

A novel fixation method for unstable ankle fractures in the elderly using dual percutaneous tibiotalar cannulated screws

Ankle fractures in the elderly are often complicated by osteoporosis and poor skin quality, resulting in poorer outcomes. This retrospective case-series describes a novel minimally invasive fixation method for managing unstable ankle fractures in the high-risk elderly patient. Six elderly patients who underwent dual tibiotalar cannulated screw fixation for unstable ankle fractures between January 2019 and 2020 were identified. Data on post-operative pain scores, mobility and complications were collected. Pre- and post-operative radiographs were analysed for fracture type and complications. Functional outcomes were excellent with 83.3% of patients pain free, and 100% ambulatory with walking-aids at 10.25 months follow-up. Four of the six patients (66.7%) had satisfactory post-operative radiographs, and there were no soft tissue injury or infections due to the surgery. Dual percutaneous tibiotalar cannulated screws can be used to manage unstable ankle fractures in the low demand elderly patient, resulting in excellent functional outcomes.

HTX-011 effectively reduces postoperative pain intensity and opioid use in the elderly

Aim: HTX-011 (ZYNRELEF™) is an extended-release, dual-acting local anesthetic containing bupivacaine and meloxicam. In bunionectomy and herniorrhaphy studies, HTX-011 resulted in less postoperative pain and less opioid consumption versus bupivacaine HCl. Here we evaluate HTX-011 in patients aged ≥65 years. Materials & methods: Patients received placebo, bupivacaine HCl or HTX-011 following surgery. End points included pain intensity, total opioid consumption, opioid-free patients and safety. Results: HTX-011-treated patients reported lower postoperative pain through 72 h versus bupivacaine HCl and placebo. Elderly patients administered HTX-011 used fewer opioids versus bupivacaine HCl, and a greater proportion remained opioid-free through 72 h. HTX-011 was well tolerated with a safety profile similar to bupivacaine HCl and placebo. Conclusion: HTX-011 maintained effectiveness and was well tolerated in elderly patients. Clinical Trial Registration: NCT03295721 and NCT03237481.

Efficacy and safety of US-guided thermal ablation for primary hyperparathyroidism: a systematic review and meta-analysis

Purpose: To summarize the published literature on thermal ablation for primary hyperparathyroidism (PHPT) and to evaluate the effectiveness and safety of thermal ablation as a novel treatment strategy.Materials and methods: Two authors carried out the literature search using four databases independently, including PubMed, Embase, Cochrane, and Web of Science. The meta-analysis included prospective and retrospective data that compared post-ablative outcomes to pre-ablative values. The primary outcomes were parathyroid hormone (PTH), serum calcium and volume of the parathyroid gland (VPG).Results: From the 184 original articles, five studies (4 retrospective studies and 1 prospective study) examining 84 patients met the inclusion criteria. The meta-analysis showed significant reduction of PTH at 3 (standardized mean difference (SMD) =  -1.09, 95% confidence index (CI) =  -1.42 to -0.76, p < 0.001) and 6 months (SMD =  -1.13, 95% CI =  -1.46 to -0.80, p < 0.001) after thermal ablation. Serum calcium level was significantly reduced at 3 (mean difference (MD) =  -0.31, 95% CI =  -0.50 to -0.12, p  =  0.001) and 6 months (MD =  -0.31, 95% CI =  -0.46 to -0.17, p < 0.001) after thermal ablation. There was no significant difference between pre-ablative VPG and that of 6 months after ablation (MD =  -0.30, 95% CI =  -0.70 to 0.09, p  =  0.13). The most common complications were transient dysphonia and subcutaneous edema. No major complications or death occurred.Conclusion: Thermal ablation is effective and safe for treatment of PHPT. PTH and calcium levels were reduced significantly at 3 and 6 months after thermal ablation.

Rectal Prolapse Repair with Abdominal Fixation Under Sedation and Local or Epidural Anesthesia: Prospective Pilot Study in 10 Elderly Subjects

Background: Rectal prolapse (RP) is primarily a disease of the elderly, where treatment may be associated with significant postoperative morbidity including that related to anesthesia. Objective: The aim of this study was to evaluate the safety and feasibility of a novel abdominal approach to RP repair under sedation and local anesthesia and to assess short- and long-term clinical outcomes in elderly patients (>70 years). Design Settings: This is a prospective pilot study with 10 patients using a novel RP repair. The anesthesia type was local or epidural with sedation. Follow-up was done at 30 days, 12, and 24 months. Patients: Patients were men and women >70 years of age with RP. Main Outcome Measures: (1) Feasibility: successful completion of RP repair using the novel abdominal approach with laparoscopic assistance. (2) Safety: safety was measured by the incidence of the intraoperative complications (bowel perforation, organ injury, and bleeding requiring blood transfusion). (3) Sedation and local anesthesia feasibility: surgery was safely completed without patient intubation. Results: Ten female patients >70 years of age underwent RP repair using the novel abdominal approach. General anesthesia was not required in any of the 10 patients. Two patients recurred within 6 months. One of the patients with recurrence of RP subsequently underwent laparoscopic rectopexy, and the other was minimal and required no further treatment. One mortality occurred at 3 months unrelated to the procedure. No other anesthetic or surgical intraoperative and postoperative complications were observed. Limitations: This is a single-institution pilot study. Conclusions: Abdominal RP repair under sedation and regional anesthesia appears feasible and safe in elderly patients and may, in the future, provide an effective alternative to current treatment options for RP, avoiding general anesthesia. ClinicalTrial.gov registration number: NCT01980043.

An Analysis of Anesthesia Induction Dosing in Female Older Adults

BACKGROUND/OBJECTIVES

In the context of an aging surgical population, appropriate anesthetic induction dose adjustments for the older adult remain poorly defined. In the present study, we describe the prevalence of excess induction agent dose in reference to US Food and Drug Administration (FDA) guidance and seek to investigate the possible association of such excess dose with postinduction hypotension and postoperative acute kidney injury (AKI).

STUDY DESIGN

A retrospective observational study was conducted in a large tertiary teaching hospital in accordance with our a priori analytic protocol as registered on ClinicalTrials.gov (NCT03699696). For inclusion, patients had to be 65 years or older and to have received general anesthesia with propofol induction for gynecologic oncology surgery between December 1, 2014 and July 8, 2018. Descriptive variables of the patients, machine-captured perioperative vital signs, induction anesthetic, and vasopressor/inotrope administrations were recorded.

MAIN OUTCOME MEASURES

A total of 541 female patients met inclusion criteria. The mean (standard deviation) age of the cohort was 72.20 (5.93) years. Regarding the primary outcome, 65.43% (354 patients, 95% confidence interval 61.2-69.4) of the cohort received more than the FDA recommended 1-1.5 mg/kg induction dose for patients of advanced age undergoing general anesthesia.

RESULTS

The percentage of patients receiving doses in excess of the FDA guidance remained substantial across all age groups, but decreased progressively with increasing 5-year age intervals (from 74% among those aged 65-69 years to 44% among those aged > 80 years). Excess propofol dose in the present cohort was not associated with our a priori definition of postinduction hypotension. Regarding AKI, among the 30 patients suffering this outcome, it occurred less often in patients who received higher propofol doses (4.1% [9/217] vs. 15.3% [21/138], p < 0.001), a result that may have been confounded by differential rates of missingness.

CONCLUSIONS

Older adults commonly receive propofol induction doses in excess of the FDA guidance. The immediate hemodynamic effects of these doses on postinduction hypotension were not seen in the present cohort, suggesting that propofol dose adjustments may serve as a marker of physicians' judgments as to the frailty of patients. The relevance of the AKI association is difficult to interpret due to the non-differential missingness of AKI data between the two groups.

Procedural sedation and analgesia for percutaneous high-tech cardiac procedures

The interest in percutaneous high-tech cardiac procedures has increased in recent years together with its safety and efficacy. In fragile patients, procedural sedation and analgesia are used to perform most of the procedures. General anesthesia remains the technique of choice during the team learning curve and might be required in selected patients or in emergent situations. Despite the high costs of percutaneous high-tech cardiac procedures, the decrease in length of hospital stays, rate of intensive care admission and complications, balance the increase in devices costs. In fragile patients who undergo percutaneous high tech cardiac procedures, the primary role of the anesthesiologist is to prevent the need for postprocedural intensive care unit and complications rate. Starting from the experience of a large university third level hospital we identified the eight most commonly performed contemporary percutaneous high tech cardiac procedures (ventricular tachycardia and atrial fibrillation ablation, protected percutaneous coronary intervention, transcatheter aortic valve implantation, MitraClip® (Abbott Laboratories; Abbott Park, IL, USA), percutaneous patent foramen ovale closure, left atrial appendage closure, and dysfunctional lead extraction), discuss the role of procedural sedation and analgesia in this setting, and explore future perspectives.

Anesthetic management of a "Supercentenarian" (Oldest living person on Earth) posted for an emergency surgery

With the rise in living standards and evolution of science, there is a rise in life expectancy world over. This demographic transition has led to a rise in older persons, increasing the dependency ratios and “demographic burden.” Management of such old patients requires special considerations and understanding as aging is a physiological phenomenon in which the functional capacity of organs decreases due to degenerative changes in the structure. An important aspect to remember in Geriatric Anesthesia is that in spite of adequate compensatory mechanisms for age-related changes, there is a limitation of physiological reserve, especially in stressful circumstances like perioperative period. Geriatric patients are more sensitive to all medications and anesthetic agents. Lesser amount of drug is required to achieve the desired clinical effect, but have a prolonged effect. This elderly but well-preserved patient, possibly a case of small gut obstruction was posted for emergency laparoscopy and proceed. Seeing his age and easy friability, a well-planned preoperative assessment and optimization was done prior to wheeling him into operation theater. Administration of short-acting anesthetic drugs in titrated quantities and awareness about postoperative cognitive dysfunction (POCD) helped us to get better and faster recovery in the patient.

Neuroplasticity induced by general anaesthesia: study protocol for a randomised cross-over clinical trial exploring the effects of sevoflurane and propofol on the brain - A 3-T magnetic resonance imaging study of healthy volunteers

BACKGROUND

Although used extensively worldwide, the effects of general anaesthesia on the human brain remain largely elusive. Moreover, general anaesthesia may contribute to serious conditions or adverse events such as postoperative cognitive dysfunction and delirium. To understand the basic mechanisms of general anaesthesia, this project aims to study and compare possible de novo neuroplastic changes induced by two commonly used types of general anaesthesia, i.e. inhalation anaesthesia by sevoflurane and intravenously administered anaesthesia by propofol. In addition, we wish to to explore possible associations between neuroplastic changes, neuropsychological adverse effects and subjective changes in fatigue and well-being.

METHODS

This is a randomised, participant- and assessor-blinded, cross-over clinical trial. Thirty healthy volunteers (male:female ratio 1:1) will be randomised to general anaesthesia by either sevoflurane or propofol. Multimodal magnetic resonance imaging (MRI) of the brain will be performed before and after general anaesthesia and repeated after 1 and 8 days. Each magnetic resonance imaging session will be accompanied by cognitive testing and questionnaires on fatigue and well-being. After a wash-out period of 4 weeks, the volunteers will receive the other type of anaesthetic (sevoflurane or propofol), followed by the same series of tests. Primary outcomes: changes in T1-weighted 3D anatomy and diffusion tensor imaging.

SECONDARY OUTCOMES

changes in resting-state functional magnetic resonance imaging, fatigue, well-being, cognitive function, correlations between magnetic resonance imaging findings and the clinical outcomes (questionnaires and cognitive function). Exploratory outcomes: changes in cerebral perfusion and oxygen metabolism, lactate, and response to visual stimuli.

DISCUSSION

To the best of our knowledge, this is the most extensive and advanced series of studies with head-to-head comparison of two widely used methods for general anaesthesia. Recruitment was initiated in September 2019.

TRIAL REGISTRATION

Approved by the Research Ethics Committee in the Capital Region of Denmark, ref. H-18028925 (6 September 2018). EudraCT and Danish Medicines Agency: 2018-001252-35 (23 March 2018). www.clinicaltrials.gov , ID: NCT04125121 . Retrospectively registered on 10 October 2019.

THE IMPORTANCE OF NON-INVASIVE REGIONAL BRAIN OXIMETRY IN PREVENTING POSTOPERATIVE COGNITIVE DYSFUNCTION DURING LAPAROSCOPIC CHOLECYSTECTOMY IN ELDERLY AND SENILE PATIENTS

The adverse effect of general anesthesia in elderly patients during surgery requires monitoring of functions and processes to identify their dangerous abnormalities to prevent complications. The aim of the study. To establish the effectiveness of non-invasive regional brain oximetry with rSO2 determination during anesthetic support in laparoscopic cholecystectomy (LCE) to prevent postoperative cognitive dysfunction in elderly and senile patients. Material and methods. 84 elderly and senile patients with diagnosed gallstone disease, acute cholecystitis, who underwent LCE with sevofluran inhalational anesthesia and total intravenous anesthesia with propofol were examined. rSO2 was monitored. Cognitive functions were assessed using neuropsychological scales and the MMSE mental state examination scale. Results. rSO2 was found to be significantly decreased during the carbon dioxide insufflation as compared to before premedication: in LH (left hemisphere) – by 7.0 %, in RH (right hemisphere) – by 6.9 % (Group I); in LH – by 7.4 %, in RH – by 7.5 % (Group II). rSO2 was significantly increased during the surgery, particularly in the middle of the operation, as compared to before premedication: in LH – by 14.66 %, in RH – by 13.94 % (Group I); in LH – by 11.60 %, in RH – by 11.53 % (Group II). The day following the surgery, cognitive functions significantly decreased by 8.7 % on the Luria's test, by 6.0 % on the MMSE test (Group I); in Group II – by 10.1 % and 6.3 %, respectively, as compared to before premedication. On Day 5 after the surgery, cognitive functions decreased by 2.7 % on the Luria's test, by 0.35 % on the MMSE test (Group I); in Group II – by 2.7 % and 0.35 %, respectively, as compared to before premedication. Conclusions. A decrease in rSO2 can occur during LCE in the Trendelenburg position, despite the fact that other intraoperative indicators remain stable, which allows it to remain unrecognized. rSO2 monitoring in the perioperative period contributes to alertness and timely measures to prevent postoperative cognitive dysfunction.

S100B protein and neuron-specific enolase as predictors of postoperative cognitive dysfunction in aged dogs: a case-control study

OBJECTIVE

Postoperative cognitive dysfunction (POCD) may be related to brain injury. S100B protein and neuron-specific enolase (NSE) have been investigated as potential biochemical markers of neural cell injury in animals and humans. This study aimed to investigate the association between POCD, brain injury and serum concentrations of S100B and NSE after periodontal surgery in aged dogs.

STUDY DESIGN

Prospective observational animal study.

ANIMALS

A total of 24 male and female dogs undergoing periodontal surgery.

METHODS

Dogs were separated into two groups based on age: control group, 10 dogs ≤ 8 years and aged group, 14 dogs > 8 years. Cognitive function was measured preoperatively and on the seventh postoperative day using the Canine Cognitive Dysfunction Rating scale and the Age-Related Cognitive and Affective Disorders scale. S100B protein and NSE serum concentrations were measured before and immediately after the surgery.

RESULTS

POCD was not observed after surgery in the present study. Serum concentrations of S100B and NSE were increased postoperatively in the control group but not in the aged group (p = 0.04 and 0.03, respectively). Preoperative S100B serum concentrations were significantly higher in the aged group (p = 0.01).

CONCLUSIONS

There was no association between POCD and high concentrations of S100B and NSE in dogs. However, increased postoperative serum concentrations of S100B and NSE were found in the control group after surgery, an effect that may indicate neural damage.

CLINICAL RELEVANCE

The results suggest that anesthesia and oral surgery are associated with higher postoperative serum concentrations of S100B and NSE in dogs ≤ 8 years old, which may indicate neural damage. Serum concentrations of S100B were elevated in aged dogs before anesthesia, a finding that might be related to chronic preoperative brain damage.

Vaginal hysterectomy with anterior and posterior repair for pelvic organ prolapse under local anesthesia: results of a pilot study

INTRODUCTION AND HYPOTHESIS

Vaginal hysterectomy (VH) and pelvic floor repair (PFR) for the surgical management of pelvic organ prolapse (POP) are usually performed under regional anesthesia. The aim of this study is to evaluate the feasibility of performing VH and PFR under local anesthesia and to compare postoperative pain and patient recovery parameters with patients undergoing the same surgical procedure under regional anesthesia.

METHODS

This was a single-center prospective cohort study of women with advanced POP. The standard care group consisted of 20 patients who underwent VH and PFR under a combined spinal-epidural (CSE) block, whereas the local anesthesia group consisted of 20 patients who underwent VH and PFR under local anesthesia and intravenous sedation. Primary outcomes included the intensity of postoperative pain and the percentage of patients with moderate/severe pain. Secondary outcomes included percentage of patients who used opioids, incidence of nausea/vomiting, level of sedation, and patient satisfaction rate.

RESULTS

The median pain intensity at rest was significantly lower in the local anesthesia group at 2 h, 4 h, and 8 h postoperatively (median values: 0 vs 1.9, 0 vs 4.1, and 1 vs 2.7 respectively). The percentage of patients needing opioids was significantly lower for the local anesthesia group (35% vs 95%, p = 0.002). The proportion of patients presenting nausea and vomiting symptoms in the two groups was similar.

CONCLUSIONS

Local anesthesia for patients undergoing VH and PFR has been shown to be a viable alternative to regional anesthesia, offering reduced postoperative pain and less opioid use for the first 8 h.

Anaesthesia-dependent oscillatory EEG features in the super-elderly

OBJECTIVE

Although the characteristics of electroencephalograms (EEGs) have been reported to change with age, anaesthesia-dependent oscillatory features and reactivity of the super-elderly EEG to anaesthesia have not been examined in detail.

METHODS

Participants comprised 20 super-elderly patients (age; mean ± standard deviation, 87.1 ± 3.8 years) and 20 young adult patients (35.5 ± 8.5 years). At three levels of sevoflurane anaesthesia (minimum alveolar concentration [MAC] of 0.3, 0.7, and 1.4), oscillatory features of the frontal EEG were examined by analysing quadratic phase coupling (bicoherence) and power spectrum in α and δ-θ areas and compared in an anaesthesia-dependent manner, using the Friedman test.

RESULTS

Among super-elderly individuals, bicoherences in the δ-θ area showed anaesthesia-dependent increases (median [interquartile range], 12.9% [5.2%], 19.2% [9.1%], 23.3% [8.7%]; 0.3, 0.7, 1.4 MAC sevoflurane, p = 0.000), whereas bicoherence in the α area did not change at these different anaesthesia levels (11.2% [3.9%], 12.5% [4.4%], 14.1% [5.7%], respectively; p = 0.142), counter to the results found in young adult patients, where both δ-θ and α bicoherences changed with anaesthesia.

CONCLUSIONS

In the super-elderly, δ-θ bicoherence of EEG shows anaesthesia- dependent changes, whereas α activity remains small irrespective of anaesthesia level.

SIGNIFICANCE

Quantification of δ-θ bicoherence is a candidate for anaesthesia monitoring in the super-elderly.

Perioperative probiotic treatment decreased the incidence of postoperative cognitive impairment in elderly patients following non-cardiac surgery: A randomised double-blind and placebo-controlled trial

BACKGROUND

Given that population aging is a global health challenge, the high prevalence of postoperative neurocognitive impairment in elderly patients necessitates the development of novel simple and effective prevention methods.

OBJECTIVE

To evaluate the effects of perioperative application of oral probiotic as a prophylaxis for cognitive impairment in elderly patients following non-cardiac surgery.

METHODS

This randomised double-blind and placebo-controlled trial included 120 elderly patients (in a modified intention-to-treat analysis) scheduled for elective orthopaedic or colorectal surgery. Patients were assigned to receive either probiotics or a placebo from hospital admission until discharge. The primary endpoint was the incidence of postoperative cognitive impairment, defined as a decrease of ≥3 points in the Mini-Mental State Examination (MMSE) scores from admission baseline to the 7th day post-surgery. Secondary endpoints included changes in plasma interleukin-6 (IL-6) and cortisol, postoperative pain intensity, postoperative sleep quality, gastrointestinal function recovery, and faecal microbiota composition.

RESULTS

The incidence of postoperative cognitive impairment in the probiotic group was significantly lower than in the control group (3 of 59 patients [5.1%] vs. 10 of 61 patients [16.4%], P = 0.046). In addition, compared to pre-surgery, the levels of plasma IL-6 and cortisol in the probiotic group decreased more than in the control group 5-7 days after surgery (IL-6: -117.90 ± 49.15 vs. -14.93 ± 15.21, P = 0.044; cortisol: -158.70 ± 53.52 vs. 40.98 ± 72.48, P = 0.010). Relative abundance at the genus level in the faeces of the probiotic group also changed more than in that of the control group during the perioperative period. In contrast, postoperative pain intensity, sleep quality, and gastrointestinal function recovery did not differ significantly between the two groups.

CONCLUSION

Perioperative application of oral probiotic prevents postoperative cognitive impairment in elderly patients following non-cardiac surgery, possibly via the limitation of peripheral inflammation and the stress response.